In light of the ongoing civil unrest in the United States, I wanted to use this month’s Founder Letter as a way to engage with the physical therapy community—a group that includes peers, colleagues, and friends—about the topic of diversity. My hope is to spark meaningful, productive conversations surrounding racial disparity in rehab. As someone with a platform, I feel it is my duty—as well as my privilege—to promote and model a more equitable and inclusive environment for practice leaders, clinical staff, non-clinical staff, and patients alike.
I realize that in writing about this topic, I am inviting an opportunity for heated—and potentially uncomfortable—discourse. All it takes is a simple scroll through the comments beneath any recent article covering race and inequality to know that this topic incites strong reactions—both positive and negative. Still, I believe I have an obligation as a healthcare provider—and a business leader—to (1) think critically about issues surrounding systemic racism, (2) examine the ways it impacts patient health and access to care, and (3) discuss strategies to improve treatment delivery by promoting diversity, equity, and inclusion in the physical therapy industry. It is my hope that you will read this with an open heart and an open mind.
Inclusivity starts with the individual.
Fostering diversity and creating a more inclusive practice is not an overnight transition. And just like any massive undertaking, the work starts at home. As I mentioned before, I believe it is our moral imperative as physical therapists to do everything in our power to improve patient health and well being—and part of that is cultivating an environment of understanding, empathy, and inclusion. To accomplish this, PTs can start by making minor adjustments to their own interactions with patients and colleagues—something that is bound to create a ripple effect.
1. Seek learning opportunities on the causes and effects of systemic racism in healthcare and the physical therapy community.
One of the best things individual therapists can do to cultivate diversity and mitigate potential unconscious bias is to self-educate and listen. There are plenty of resources available to those who wish to learn—from books and research papers to podcasts and documentaries—and many are available online free of charge. It’s a massive topic, so if you’re not sure where to start, I’d suggest familiarizing yourself with definitions of words that are now commonplace (e.g., systemic racism, racist, anti-racist, etc.). It’s not enough to simply acknowledge that systemic racism exists in the PT community; we must also educate ourselves on why it exists in the first place. As you do your research, I encourage you to vary your sources and specifically seek out educational materials that come directly from voices in marginalized communities. A great example is Justice in June, which I am proud to say some WebPTers helped to make available to the public. As you start consuming information, share your findings with people who are open to thoughtful discussion. These types of conversations are just as beneficial for you as they are for the people to whom you speak.
I also recommend taking part in any formal educational opportunities available to you. Many educational institutions—including Yale, Columbia, and Harvard—are offering free online courses on the topics of race and diversity. And when you participate in PT industry conferences—online or in-person—make it a point to attend sessions focused on diversity in our profession. What better way to educate yourself than in a room full of your peers?
2. Be mindful of word choice when interacting with colleagues and patients.
Something we can all do right now is examine the language we use when communicating with—or referring to—individuals from minority groups. (For reference, this resource has a robust list of terms and guidelines for using inclusive language in the workplace.) Certain words or phrases—even when spoken without malicious intent—still communicate a sense of “otherness” to people of minority backgrounds. An example would be referring to an individual as your “______ patient” or “______ coworker,” wherein the blank is filled by that person’s ethnicity, skin color, sexual orientation, or religion—specifically, in cases where that descriptor is irrelevant to the conversation. Often, this reinforces embedded stereotypes, expectations, and the sense that society will always view that individual as a “______ person” instead of simply a person.
Furthermore, it’s important to maintain an open mind and a willingness to listen if you are ever corrected on your word choice—particularly if the person correcting you is from the community you referenced. Missteps are inevitable on the road to change, and terminologies can evolve over time. The important thing is that you’re open to learning.
3. Examine implicit bias and consider how it might impact your interactions with patients.
You’ve likely heard the term “implicit bias” before, but if not, here’s the quick definition: implicit biases are the unconscious beliefs every person has based on stereotypes and societal norms. You’ll note that I said every person—not just some people. For this reason, broaching the topic of implicit bias can be touchy. Most of us don’t want to think of ourselves as having biases—particularly when it comes to minorities or underserved communities. But unlike explicit bias, implicit bias isn’t a conscious choice. Rather, it’s the result of a lifetime of social conditioning that causes us to tie specific qualities to a given demographic. Having implicit biases doesn’t make someone a bad person—it’s simply part of the human condition. However, implicit biases can lead us to make unconscious assumptions about a person based solely on appearances. And as physical therapists, it’s critical that we understand how those assumptions can impact patient treatment. In 2003, the Institute of Medicine in Washington, DC, conducted a report on unconscious bias in healthcare settings that “concluded that unrecognized bias against members of a social group, such as racial or ethnic minorities, may affect communication or the care offered to those individuals.”
While some studies have implied a correlation between implicit bias and patient outcomes, it’s a topic that warrants further exploration. However, we do know that implicit biases can alter the way we communicate with each other—whether that be communication between PTs and patients or PTs and their colleagues.
Recognizing and deconditioning unconscious bias takes a concerted effort, but here are a few actions PTs can take to identify biases and address them:
- Taking Implicit Association Tests (IATs) and reflecting on potential biases.
- Making a list of scenarios that could potentially elicit bias.
- Thinking critically before reacting or responding when those scenarios arise.
- Connecting with populations that elicit bias.
- Avoiding categorizing individuals.
- Remaining humble and acknowledging implicit biases can exist without our knowledge.
Clinic leaders are the drivers for practice-wide culture shifts.
If you’re a leader in your practice, you have the means and the authority to shape the culture and values of your team. While each staff member is ultimately responsible for self-educating and addressing individual biases and behaviors, your leadership can have a major impact on your team’s journey toward prioritizing diversity and inclusivity. There may be bumps in the road, but if you create an environment of learning and self-reflection, you’ll eventually find yourself surrounded by a team that values those same goals.
If you’ve attended any WebPT webinars, you know I believe that achieving greatness in practice starts with education. That’s why WebPT has joined an organized nationwide effort to advance diversity, equity, and inclusion in the workplace: CEO Action. I strongly encourage you to consider joining this movement with us. It focuses on inclusion via the elimination of blind spots.
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4. Consider the way implicit bias impacts your hiring decisions.
I mentioned before that unconscious bias can significantly impact how you communicate with your patients, but the importance of addressing biases doesn’t stop there. Implicit and similarity bias can also significantly affect employment practices. A 2016 study by the University of Toronto and Stanford University found that job applicants with anglicized names (i.e., caucasion-sounding names) were the most likely to receive a call back from potential employers. During the study, 25% of resumes for black applicants with caucasian-sounding names received a call back, while only 10% of applicants with traditionally black-sounding names received a call—despite both resumes being otherwise identical. For Asian applicants, 21% of resumes with anglicized names earned a call from the potential employer, while only 11.5% were contacted when their names indicated their ethnicity. Again, the education, credentials, and experience were identical on both versions of the resumes.
This isn’t to say that those employers or hiring managers were explicitly racially biased. In fact, the study had similar results when applications were specifically sent to employers who claimed to be pro-diversity and thus, actively sought applicants of color.
So, what does this mean? To me, it says that even the most well-intentioned employers are prone to unconscious racial bias. It also tells me that we must make a concerted effort to recognize, educate, and negate implicit bias in our recruitment practices. This starts with scrutinizing current hiring practices and ideally, enacting a blind recruitment process—meaning demographic information that may imply an applicant’s race, gender, age, or economic class is removed from resumes before they reach your desk.
Additionally, practices can regularly check their screening processes for discrimination by weighing the percentage of minority applicants against the percentage of those applicants who made the initial cut.
5. Foster an environment that encourages accountability, empathy, and growth.
Let’s face it: discussions around race and inequality are often uncomfortable. I think in most cases, our knee-jerk reaction is to reject racism and any role we might play in it, because of course we don’t want to think of ourselves as racist. These discussions challenge our sense of self, and they ask us to question our own actions—even the unconscious ones. They also force us to re-examine seemingly innocuous tendencies and beliefs we’ve held our entire lives.
Whether the topic is race, religion, or politics, finding yourself in a situation where you’re asked to question a deeply-held belief is like asking your arm to bend in the opposite direction. So, it stands to reason that an individual’s initial reaction to such situations may not be a receptive one. However, with a little patience and encouragement, people often change their minds. So, if you find yourself interacting with someone who doesn’t immediately “get it,” it’s okay. But more importantly, you should promote an environment of learning that allows these individuals to come back later if they’ve had a change of heart—without fear of ridicule or belittlement.
The entire physical therapy profession has a part to play.
This is one of those potential knee-jerk moments, but I hope you’ll keep an open mind to what you’re about to read: nearly every modern system in the United States has been impacted by racial inequity in some way, and unfortunately, health care—including physical therapy—is no exception. I won’t delve too deep into the roots of this disparity—there are many—but I encourage you to do your own research on the subject, as I believe it can help us come up with ways to better address it.
6. Consider the social determinants of health and how diversifying the profession can improve outcomes.
Historical data on the number of black providers in the United States sheds a harsh light on the very real racial disparity across all areas of health care. Around the year 1900, about 2% of medical professionals were black—a number that did not budge until the 1980s, despite the growing black population in the country. Today, about 5% of physicians in the US self-identify as black, according to the Association of American Medical Colleges. Compare that to the 13.4% of Americans who identify as black, and the disparity is easy to see.
With that historical data in mind, let’s shift the focus back to PT. In 2019, WebPT conducted our third-annual State of Rehab Therapy industry survey. Of the 6,000 individuals who responded to our survey—including occupational therapists and speech-language pathologists—a mere 2.2% self-identified as black or African-American. That’s nearly identical to the percentage of black medical doctors who practiced during the era of Jim Crow and segregation. This number aligns with the APTA’s most recent demographic analysis of its member population: as of 2017, only 1.5% of APTA members identified themselves as black or African American.
The black community is not the only one that experiences disparity. Our 2019 industry survey found that 4% of rehab therapy professionals identify as Hispanic or Latino, while the APTA reported that a mere 2.5% of its members identify the same way. However, 2019 US census data tells us that Hispanic and Latino individuals make up about 18.5% of the population.
The Impact on Physical Therapy Treatment
You might be wondering about the implications of this data when it comes to treating patients. After all, a talented PT can provide excellent care to any individual regardless of the patient’s race or ethnicity, right? While that may be true, a lack of diversity can often impede patients from seeking care in the first place. A recent study from the National Bureau of Economic Research found that black men seen by black doctors agreed to undergo more preventive services—as well as more invasive treatments—than those seen by non-black doctors, an effect that was said to be “driven by better communication and more trust.”
This revelation is especially prudent for physical therapists. Quality health care—and physical therapy, in particular—is driven by human connection, and patients can more easily connect with providers when their relationship is built on mutual understanding and trust. Conversely, if patients don’t trust their providers or feel misunderstood by them, it gives those patients a reason to not return for care—or to not seek it at all. And considering that only 10% of patients who could benefit from physical therapy actually receive it, this is a missed opportunity to solve the so-called “90% problem.” But more importantly, health outcomes and life expectancy are significantly lower for people of color compared to the white population, and we should be striving toward any solution that can help mitigate that trend.
7. Press universities to consider a holistic admissions approach that supports a diverse student population.
As we face these discouraging numbers, we must ask ourselves why there is such a massive disparity between the number of white PTs and the number of PTs of color; then, we must come up with ways to address that disparity. To me, one very obvious place to start is with PT education.
In 2018, faculty from the University of Colorado’s School of Medicine hosted a session at the APTA’s Combined Sessions Meeting (CSM) that addressed this very issue. During the session, the presenters discussed their experience with restructuring the admissions processes for DPT programs in order to cultivate a more diverse workforce. The speakers presented findings they collected after employing tools in their own admission process that:
- accounted for both cognitive and non-cognitive factors, and
- fostered a more holistic approach to admission selections.
They noted that an applicant’s test-taking ability or cumulative GPA was not necessarily an accurate representation of the kind of PT he or she would become. (They did, however, note that academic performance in math and sciences is highly valuable when assessing an applicant’s potential for success as a physical therapist.) So, in addition to test scores and GPA, the admissions staff also considered non-cognitive assessment methods such as emotional intelligence and grit score.
Recruitment efforts should start as early as possible.
This session spurred a lot of discussion around the need for a more diverse applicant pool. One commenter—a faculty member at Northern Illinois University—mentioned that it’s hard for diversity initiatives to be successful when you’re pulling from the same pool every year. She recommended working with local professional chapters to assist in recruitment efforts. Another commenter from the University of Arkansas said we must get adolescents in the PT pipeline from the moment they become interested in health care (as early as high school, middle school, or even elementary school). Far too often, when high school students speak with guidance counselors about a career in health care, those students are funneled into a physician path—unless they specifically express an interest in PT.
The presenters also noted the need for inclusivity across all stages of the PT career, not just during the school admissions process. According to Lara Canham, a faculty member from the University of Colorado, “[Diversity] can’t be a program-level effort. It needs to be a national effort; a societal effort, if we want to see change.”
8. Support PT-led, minority-focused organizations.
Still, once we have greater diversity in the PT education system, we must continue supporting these clinicians beyond graduation day by ensuring they have equal opportunities for success. Diversity can be metrics-driven and measured, but inclusion is a choice. I believe one very important component of ensuring continued success is to endorse and advocate for organizations that support these future PTs. Two organizations that come to mind are the National Association of Black Physical Therapists, Inc. and PT Proud, an advocacy group supporting patients and providers in the LGBTQ+ community. By reaching out to these groups, we can learn how to be better leaders, better colleagues, and better PTs—as well as better allies.
This is not a PT-specific issue.
As we discuss ways to cultivate inclusivity with our patients and within our practices and profession, we cannot forget about our healthcare peers outside of physical therapy. As PTs, we must hold ourselves accountable for the systemic effect of inequality within not only our own profession, but also the healthcare industry at large. After all, as we strive to work with physicians and other rehab therapists as part of integrated care teams, we must first be the change we wish to see.
9. Support efforts for inclusivity in physician education practices.
Just as we should push for greater inclusivity in physical therapy education, the entire medical community could benefit from re-examining their education practices. I believe medical programs—as well as other healthcare professional programs—should consider ways they can foster diversity during the admissions process.
That said, simply leveling the playing field isn’t enough. Historically, people of color have had less access to higher education, which is part of a much larger issue within our society. For that reason, universities must find opportunities to reach adolescents within these communities and provide pathways to students who wish to pursue healthcare careers.
Diversity efforts must also extend to the academic awards process.
With that in mind, the acceptance rate for medical students from minority communities isn’t the only area of higher education that warrants further review. In 2017, a collaborative study examined the admittance rate of medical students to one of the most prestigious medical honor societies. Upon review, black and Asian applicants were far less likely to be admitted than white applicants. Considering the impact such awards have on future employment and grant funding opportunities, this disparity could end up putting minority students at a disadvantage.
10. Push for inclusivity in the way our technology and systems are built.
As a PT in technology, I would be remiss to overlook the role tech systems can play in fostering greater inclusivity in health care. A challenge that many who use EMRs and EHRs run into—and one that has been brought to my attention personally—is the lack of gender-inclusive terminology in electronic patient charts. While changing gender terms seems like an easy back-end fix, the lack of cohesion among various EMR/EHR products and other platforms (e.g., billing software) means adding more nuanced gender options creates an interoperability dilemma. Namely, if the payer recipient is not also updated with those same terms, it could lead to incomplete data transmission and denied claims. Correcting this issue at scale will require cooperation and a united commitment to diversity across the entire health IT community—not just one or two companies. However, the WebPT team is currently testing ways to make this change within our platform—an effort we hope will lead the charge for transformation within the industry at large.
2020 has been a year for the books, and I don’t think it’s controversial to say that we’re witnessing history in the making. The message behind the Black Lives Matter movement—and the voices spreading that message—has forced every community to think critically about their role in systemic racism and the actions they can take to create lasting, meaningful change. Granted, that change won’t happen overnight; we have a lot of work to do with ourselves, our businesses, and our communities. But as long as we listen, maintain empathy, and stand in solidarity with those who speak out against inequality and injustice, I believe we will see a better tomorrow—for everyone.