Feature Who Are Tomorrow's PTs and PTAs? As the patient population becomes more diverse, are physical therapy providers keeping up? Who are today's PTs and PTAs? Who will they be tomorrow? By Michele Wojciechowski | June 2018 Muhammad Alrwaily, PT, MS, PhD, can tell a lot about some patients with just a handshake. Or, perhaps, no handshake at all. "For a female patient who is Muslim, you have to understand that how they observe certain [religious] rules varies. Some take a more liberal view, some a more conservative one. A handshake can be a good sign of how conservative a patient is. The more conservative, the less likely she is to shake your hand," explains Alrwaily, himself Muslim. "If you are a male physical therapist [PT] and a female patient who is Muslim does not want to shake your hand, consider offering her the care of a female PT," Alrwaily continues. "Also, privacy is an essential component for these patients. Since they care about modesty and tend to cover up their bodies and heads, examining and treating the patient in a private room might be the best way to go." That advice helps illustrate the value of clinicians keeping up with the diversification of the patient population. "The profession of tomorrow hopefully will look a lot more like the population we serve, which is becoming more diverse each day," says Johnette L. Meadows, PT, MS, program director of minority/women's initiatives in APTA's Department of Practice. More broadly, "Religion is very relevant in the day-to-day life of many Muslim patients," Alrwaily notes. "Understanding the needs of the patient certainly is going to improve therapeutic alliance and therapist outcomes." He gives an example: "If we think of exercises, Muslims fast during Ramadan. They are not allowed to eat or drink from dawn to sunset. During that time, a Muslim patient may not want to participate in exercises, particularly aerobic ones that expend energy. The PT should account for that, instead employing passive exercise, soft tissue mobilization, and similar techniques—anything that does not require intensive effort while the patient is fasting." Another consideration, Alrwaily adds, is patient scheduling. "Muslims pray 5 times a day facing Mecca," he explains. "Many Muslim patients would prefer to be seen by the PT outside the prayer times. Alternatively, many would like to be offered a place for prayer within the clinic. I know a very successful dentist who has a prayer rug in a private room, with signs showing the direction to Mecca." Alrwaily, a professor at the West Virginia University School of Medicine's Division of Physical Therapy, graduated in 2007 from King Saud University in Saudi Arabia with a BS in physical therapy. He came to the United States in 2008 and earned an MS in musculoskeletal physical therapy and a PhD in rehabilitation sciences at the University of Pittsburgh. The Demographic Picture According to APTA's Physical Therapist Member Demographic Profile 2013 and a membership analysis conducted in 2017, nearly 70% (69.4%) of PT members were female and 88.5% were white.1,2 The age of the average PT was 44.1, with 18.4 years in the profession. The top employment status was full-time salaried, at 58.6%. A third of the association's PT members at that time—33%—practiced in a private outpatient office or group practice. But the times, they are a changin'. See "Demography Is Destiny" on page 38 for some predicted changes. In addition, as Alrwaily noted, cultural and religious beliefs can be manifested in many different ways. "Diversity is very complex, in that it includes many facets of a person's culture and makeup," Meadows points out. "PTs and PTAs [physical therapist assistants] must consider the layers of culture that may affect a person's ideas about health care, wellness, and health in general. We should never base decisions on what a single part of a person's 'culture' may dictate, because that can lead to making judgments based on stereotypes. In many cities and states today, there no longer is a 'majority' culture. States such as California now are made up of multiple 'minority groups,' as no single group dominates," she says. APTA, meanwhile, has been taking a variety of steps to embrace cultural competence and increase diversity within the profession, including adoption of a Cultural Competence/Diversity Plan.3 (See "APTA: Increasing Diversity" on the facing page.) International and Interprofessional Experiences In Haiti, physical therapy and occupational therapy students from the United States work in interprofessional health care teams with students from the nursing school at a local university. While the Haitian students tell the Americans about their hospital—its wards, their referral patterns, and the like—the Americans reciprocate by teaching the Haitian students skills they can use, such as appropriate transfer techniques for patients who have had strokes. This exchange is among the global health experiences that V. Kai Kennedy, PT, DPT, conducts in postcolonial countries and in those where people of color are in the majority. "I implement the principles of community engagement, because the American school I work with can only afford to send students abroad for a short period of time," she explains. "So, rather than having American students come in for 2 weeks, treat patients, and leave, we teach the nursing students and any other staff members of the hospital who want to learn. Then, everyone there knows, for example, how to safely transfer a patient after a stroke." But more than skills are transferred. "When I took a student who grew up in an immigrant community of New York City into rural Haiti," Kennedy continues, "he had a connection with those students that many of his classmates didn't, because he, too, was from a marginalized population. I find that American physical therapist representation in international contexts can be a powerful tool—for our students, the workforce volunteer base, and the communities we're serving." Kennedy, a 37-year-old assistant professor in the doctor of physical therapy (DPT) program at Duke University's School of Medicine, is African American. She teaches courses across the curriculum, works in clinical practice, and serves on committees that address diversity, inclusion, and cultural competence. Kennedy says that students who identify with a minority group tend to use her as a sounding board or see her as a mentor. "I'm honored by it," she says. "I've also developed a sense of responsibility, through so many of these experiences, to start asking challenging questions about what our profession is doing to address diversity-related issues so that everyone feels welcome." Diversity also applies to PTs' and PTAs' ages in general, and to specific generations in particular. (See "My Generation, Your Generation" on page 36.) Kennedy has a perspective on this issue, as well. "I'm on the generation cusp," she explains. "I'm not a Millennial, but I'm not exactly a Generation-Xer either. I love this, because I can identify with both groups—and I often can be a bridge between them." For example, Gen-Xer faculty members may feel that students having their phones out during class is disrespectful. Kennedy advises such faculty to leverage this behavior to enhance the learning process rather than detract from it. By using an app such as Poll Everywhere, she suggests, professors can ask students to vote on what they believe to be the correct answers to questions posed by the instructor. "The results come up in real time on the screen, so students, while remaining anonymous, can see what their classmates are thinking," Kennedy says. "It makes phone use less contentious and is an activity that, in fact, brings everyone together. In that scenario, phone use becomes less about checking Facebook and more about having a learning tool." On the other hand, Kennedy makes the point that less electronic device use encourages better interaction with patients. "I explain to students, 'This is what it means to sit down at eye level with patients and have conversations with them.' I point out that having their noses in their laptops detracts from that relationship." "Having been born in 1980, I can speak to both older faculty and younger students, helping each group understand where the other is coming from," she says. Providing Experience and Support Dave Kietrys, PT, PhD, is an associate professor and assistant vice chair of the Department of Rehabilitation & Movement Sciences at Rutgers University's School of Health Professions–Blackwood Campus. He is 57 years old, white, and gay. Although he has an administrative leadership role, Kietrys continues to teach musculoskeletal physical therapy and musculoskeletal pathology. He also collaborates on research in the areas of HIV-related disability and HIV-related peripheral neuropathy. He believes that his 19 years working full time in the academic arena enable him to enlighten students in ways that less-experienced and younger faculty cannot. "My experience is helpful because I've seen the trajectory of advances in our profession. I can reflect on that and shed light on how far we've come, which helps send the message to students that we are a constantly evolving and changing profession," Kietrys says. "Throughout my lectures, I give examples of how we teach spinal manipulation now. But I also note that when I attended school in the early 1980s, things were much different. My experience sends students the message that things are changing, and that you're not done with learning the day you graduate from PT school or the day you pass the boards. You're just getting started." Kietrys believes that any type of diversity among faculty, staff, and the student body encourages and attracts additional diversity. Referring to his sexual orientation, he says, "Even though I'm 'out,' I never make a declaration to my students." Rather, he allows them to figure it out on their own. For example, he keeps a photo of himself and his husband on his desk and displays a rainbow magnet on his bookshelf. "Any time we can promote diversity visually or in subtle ways—including in our marketing and admissions materials—that helps," Kietrys says. Kietrys works with Out4STEM, a mentoring and support program for high school students who identify as members of the LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, asexual) community and are interested in STEM (science, technology, engineering, and math) careers. He has spoken on panels and has lectured on such subjects as how to launch a research career and what it's like to have a career in physical therapy. His plans include directly mentoring students. It's important that the ranks of PTs and PTAs reflect society, Kietrys says. "We live in a diverse world, and our clients and patients come from diverse communities," he notes. "We should be mirroring that. We also should be welcoming people from all backgrounds into our profession. The greater our diversity, the deeper and richer our understanding will be of the needs of a varied population. We'll naturally be more sensitive to underrepresented communities—what they're going through and how they might have been marginalized, stigmatized, or treated with bias." Back Where He Belongs When Matthew Downey, PT, DPT, was growing up in Elk Grove, California, a Sacramento suburb, he knew he would go away to school—and come back. "I wanted to be an example for my community," Downey says. And that's exactly what's starting to happen. At 25, he's been out of PT school only 1 year, but he says he's already begun to see the difference he's making. Some of his patients in outpatient orthopedics at Kaiser Permanente in South Sacramento through the Kaiser Northern California Orthopaedic Residency are asking for "the new guy." While Downey had a number of role models growing up—including his father—and knew he wanted to be a role model himself, he says that being specifically requested is humbling. Downey is African American and Filipino, and he works with a diverse population. Many of his patients initially want to see an older PT. Some even have asked if he's old enough to be practicing. To address these concerns, Downey says, "I dress professionally and use professional language. I also work to be knowledgeable in what I'm presenting to the patient. I feel I get a lot of buy-in when I educate patients during the examination and tell them, afterward, how I can help them. Often, at first patients seem to be thinking 'Oh, he's young.' But after I get through the examination and tell them what I found, I usually get good buy-in." The fact that he's a local guy who returned to serve the area goes a long way with his patients. He says that patients tell him, "You're the local kid. You grew up in this area. You came back to work here. It's great that you're doing that." "A lot of studies have said that it's important for health care professionals, including PTs, to reflect the population. I think this will help improve patient outcomes as well as how we evolve as a profession," Downey says. "We're not just treating body parts; we're treating the entire person. By using our own experiences, we connect to our patients and help them as a whole." The Long and Short of It Naomi Diaz Hunter, PT, DPT, says she always wanted to work with kids. "I'm short—5 foot-3—so I don't want to work with someone who's taller than me," she jokes. "Actually, I just love working with kids." A senior PT at Cleveland Clinic Children's Hospital for Rehabilitation, Hunter, 35, works primarily with inpatients from newborn to 3 years old, most of whom have chronic respiratory failure. "They have [tracheotomy tubes] and they are on ventilators. The families need to learn how to care for them at home. Some children also have an additional diagnosis that's led to chronic respiratory failure. Some were born to moms who were addicted to drugs, especially from the opioid epidemic. Others have genetic disorders," Hunter says. The ultimate goal is to increase the children's mobility and independence. Although she can't fully know what the parents of her patients are experiencing, as a new mother herself, Hunter feels a connection. "I can talk with them as a fellow parent and explain why we or they need to do certain things that are in their children's best interests." Born in Ohio to Puerto Rican parents, Hunter didn't grow up speaking Spanish. But she does sometimes use Spanish words to make some Spanish-speaking parents of her patients feel more comfortable. Another icebreaker? "I tell them that my husband is 6 foot-3. Just saying that makes most families open up," says Hunter, "because it tells them I'm dealing with a certain type of diversity in my own household." From the Military to the Clinic Johanna Gabbard, PT, DPT, has been a PT for 33 years, a good part of that in the military. She's now 58 and working part-time as a clinical specialist at Kaiser Permanente in Oxnard, California, but she got started as a student in the US Army-Baylor University PT program in 1983. She spent 10 years on active duty, then stayed in the reserves, retiring in 2013. She also treats patients outside Kaiser and teaches online classes. Gabbard, who is Polynesian, explains that she was brought up in Southern California because her parents wanted to get a good education themselves and sought to give their children the same opportunity. "I feel like I relate to minorities, even though I don't see many Pacific islanders where I am. I work in a farming town and, consequently, see a variety of patients, many of them Hispanic. My patients are middle class and blue collar. As a minority myself, I feel that I easily connect with other minorities," she says. For nearly 15 years, Gabbard taught in the Army. While she saw some patients during that time, supervising students limited her patient load. She also helped found and run a fellowship program through Kaiser in the town of Vallejo. In the clinic, Gabbard's patients have a mix of issues, leaning more toward musculoskeletal ones. They range in age from late teens to their 80s. Why do Gabbard's patients like coming to see her? She says it could be because she's female or worked in the military, or she's athletic and spends time sailing and bike riding. "My temperament probably is my best asset," she says. "I'm pretty low key and laid back, which I imagine is appealing to minority patients who might otherwise feel intimidated by authority figures. My biggest strength is connecting with patients and helping motivate them to do what they need to do to get better." A Silent Benefit Keelin Godsey, PT, DPT, is a staff physical therapist at Spaulding Outpatient Center Orleans, part of the Spaulding Rehabilitation Network in Orleans, Massachusetts. The 34-year-old has a strong sports background and formerly competed in and coached the hammer throw. He also is a white transgender man. Godsey treats patients from across Cape Cod. He's open to sharing his gender-identification history, but he isn't "out" with his patients. "When I treat people, I like it to be all about them and not about me," he explains. "I don't want to be the focus. I worry that if I tell them, I'll become the focus—not them, their issues, their treatment," he says. At times, however, Godsey's background has proved beneficial. Two patients specifically sought him out because they, too, are transgender men. "I think that's great," Godsey says. They came to him with questions and health concerns related to prolonged binding of breasts, an issue for many transgender men. In addition to sharing his own experiences, Godsey talked to the men about how best to address their physical challenges. "Most people don't know this, but breast-binding can produce a lot of back and shoulder pain, and cause postural issues," he explains. "Binding can cause a lot of discomfort, especially because it's meant to be worn for only 8 hours, but let's be realistic. I can end up wearing mine 12 or 14-plus hours a day. A PT who is not transgender may not understand these issues." Godsey says his gender identity has allowed him to be "very open and a lot more well-rounded. Not a lot shocks me. I'm open about a variety of lifestyles, because mine is out of the ordinary. "I hope in the future there will be a lot more diversity within the physical therapy field—in terms of race, religious affiliation, gender, sexuality, and so forth," Godsey says. "Diversity adds different life experiences and beautiful perspectives. That always makes any profession better." Michele Wojciechowski is a freelance writer in Baltimore, Maryland. Additional interviews conducted by Donald E. Tepper, editor of PT in Motion. APTA: Increasing DiversityAPTA has been working to increase diversity within the profession. Goal II of the Cultural Competence/Diversity Plan1 [BOD 11-12-04-09] states, "The physical therapy workforce reflects the diversity of the population that it serves." Part of accomplishing this is stated in parts A and B under the goal: "Define cultural diversity beyond race/ethnicity" and "Increase diversity of APTA leadership." The plan will be forwarded to the House of Delegates in 2019.In addition, a portion of the APTA Vision for the Profession and its Guiding Principles states:Patient/client/consumer values and goals will be central to all efforts in which the physical therapy profession will engage. The physical therapy profession embraces cultural competence as a necessary skill to ensure best practice in providing physical therapist services by responding to individual and cultural considerations, needs, and values.2 [Emphasis added.]In total, APTA has had at least 25 policies and positions on issues relating to diversity, equity, and inclusion.One significant ongoing APTA program is its Minority Scholarship Award, which recognizes physical therapy students currently in their final year of an accredited program and faculty members who are pursuing postprofessional doctoral degrees. These awards are sponsored by the Minority Scholarship Fund and voluntary contributions. The 3 annual awards are:Faculty: Offered to minority faculty pursuing a postprofessional doctoral degree. PT Student: Offered to minority physical therapist students. In 2017, 8 students each received an award of $5,000.PTA Student: Offered to minority physical therapist assistant students. In 2017, 1 student received an award of $3,000.The Minority Scholarship fund has awarded more than $985,000 to 239 physical therapist and physical therapist assistant students and 15 faculty members pursing a doctoral degree.Nominations for 2019 will open in September. In addition, the Minority Scholarship Fund holds an annual Celebration of Diversity, with the goal of increasing the fund so that more scholarships in more significant amounts may be awarded. Contributions are tax deductible, as the fund is contained within the 501(c)(3) Physical Therapy Fund, supported by APTA.The 2018 Celebration of Diversity event, to be held October 13 in Jacksonville, Florida, will be cohosted by APTA's Section on Education and the American Council of Academic Physical Therapy, and held in conjunction with the Education Leadership Conference. Johnette L. Meadows, PT, MS, program director of minority/women's initiatives within APTA's Department of Practice, says, "It is important to have a profession that reflects the population we serve. As the profession may not be able to reach the lofty goal of having us entirely reflect the population, it becomes imperative that we make sure all people, no matter what their culture, understand the importance of cultural competence in developing treatment plans, goals, and other important aspects of physical therapist care. "Increasing the diversity of the profession and providing information on the importance and understanding of cultural competence have been part of APTA's vision, guiding principles, and mission for many years," Meadows continues. For additional information on APTA's minority and diversity programs, contact the Department of Minority Affairs at 800/999-2782, ext 3143, or email@example.com. ReferencesCultural Competence/Diversity Plan. American Physical Therapy Association; 2012. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/APTA_Adopted_Plans/CulturalCompetenceDiversityPlanBOD11-12-04-09.pdf. Accessed March 27, 2018.Vision statement for the physical therapy profession and guiding principles to achieve the vision. American Physical Therapy Association. http://www.apta.org/Vision/. Accessed March 28, 2018.The PT and PTA of TomorrowWhile visual appearance is significant, diversity goes well beyond that. "It's important to recognize that visual representation is critical," says V. Kai Kennedy, PT, DPT, adding, "Some might even argue that 'you can't be what you can't see,' but there are many constructs of diversity that are not apparent on the surface. So, what the PTs and PTAs of tomorrow look like is important, but equally so is the diversity of lived experiences, skills, and values." "I am hopeful that in the future our profession will be more diverse," she continues, "but it is imperative that we remember that diversity is not an attribute of an individual. Rather, it is a construct of a collective. Diversity is a term that speaks to the range and variance within a particular body. Diversity does not recognize 'us' and 'them.' True diversity is an attribute to which 'we' aspire," Kennedy says.Johnette Meadows, PT, MS, makes a similar point. "Each culture has layers and multiple aspects that make up an individual. There is more to diversity than what we see on the outside. It is not possible to know all there is about each individual culture, but what's crucial is knowing that culture may affect how a person interacts with the provider, and how that person sees health care and wellness. We also must be aware of the environment of each patient or client, including their extended family, and of how they interact with them. Goals must always be centered on the patient or client and be related to how they live their day-to-day lives." Meadows is program director of minority/women's initiatives within APTA's Department of Practice. Muhammad Alrwaily, PT, PhD, MS, says that PTs and PTAs should become more attuned to the psychosocial aspects of patient populations. For example, he explains, in Islam the word qadar means destiny or predestination. He says, "Gordon Waddell, MD—a lower back pain surgeon—said that lower back pain is not only about problems in the body. It's sometimes a problem that has a psychosocial aspect. Once, he went to Oman, where nearly everyone is Muslim. He noticed that people appeared to be functioning well despite their back pain. When he asked them if they felt pain, they said, 'Yes.' 'What do you do about it?' he asked them. They answered, 'It's God's will.'"Waddell told this story to show that sometimes the psychosocial makeup of the individual or the culture has a different effect on pain," Alrwaily continues. "He compared that with the Western culture, where the social emphasis on pain is completely different. In the West, when someone is in pain, they lie down and rest or seek medications." Understanding these different beliefs and attitudes is vital for PTs, he said. Alrwaily is a professor at the West Virginia University School of Medicine's Division of Physical Therapy.Dave Kietrys, PT, PhD, adds his thoughts on the future of the profession: "Some of the PTs of tomorrow will look just like the PTs of today, but I am hoping the overall composite picture will show greater diversity and more PTs coming from traditionally underrepresented backgrounds." Kietrys is an associate professor and assistant vice chair of the Department of Rehabilitation & Movement Sciences at Rutgers University's School of Health Professions–Blackwood Campus. He adds, "We definitely need more PTs who are persons of color, and more gender diversity. In terms of practice, the PTs of tomorrow will have a stronger, ongoing therapeutic relationship with their patients—such that patients will think of them as 'my PT.'"Jeremy Curtis was president of APTA's Student Assembly through May, when he graduated from Tennessee State University. Curtis, 26, an African American with a self-described inner-city background, became the first in his family to graduate from college. He credits his mom, a home health aide who worked closely with PTs, for encouraging him to become a PT.Curtis points out that US population is projected to become majority-minority in 2044. The minority population is projected to rise to 56% of the total in 2060, compared with 38% in 2014. For that reason, he says, "To provide optimal care to our patients, because we're a socially interactive profession, we have to understand the cultural differences in our patients. They have to feel comfortable working with us as professionals."In addition to the general desirability of PTs being culturally competent, Curtis suggests that schools pay particular attention to the evaluation criteria used by the Commission on Accreditation in Physical Therapy Education. It states: "Of major importance is emphasis on critical thinking, ethical practice, and provision of culturally competent service to meet the changing needs of society." Curtis comments, "Schools should consider that, especially with the trends of the population. With this shift in the population, there must be more opportunities for students to become culturally competent."He adds that during his clinicals he saw many PTAs from minority groups. Part of the reason, he believes, are cost and time factors. Many PTAs are entering physical therapy from other professions and careers. They're able to become PTAs in only 2 years at far less cost and often while working at their other job during the day.The Demography DestinyDownload the Graphic in Adobe PDF.