• Feature

    Battling Bias's Distorted Images

    Looking in the mirror is the first step.

    Battling Bias's Distorted Images

    Think of this article as the fourth part of an interconnected story in the pages of this magazine.

    In June 2018, PT in Motion looked at the importance of the profession of physical therapy embracing cultural competence and striving to better mirror in its own composition the ever-increasing diversity of the American population.1

    In July of this year, the magazine examined the need for physical therapists (PTs) and physical therapist assistants (PTAs) to consider the role of social determinants of health in their interactions with patients and clients, and in subsequent clinical decisions.2 (The US government defines social determinants of health as "conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks."3)

    This August's issue of PT in Motion followed up on the 2018 piece and looked at specific efforts by PTs, PTAs, students, and educators to better ensure that the physical therapy profession of tomorrow will reflect changing demographics and make all newcomers to the field feel welcome in a multicultural society.4  

    This feature concerns implicit or unconscious bias—which, The Joint Commission observes, "can lead to differential treatment of patients by race, gender, weight, age, language, income, and insurance status."5 The organization adds, "This difference in treatment and clinical decision-making, though unintentional, could lead to failures in patient-centered care, interpersonal treatment, communication, trust, and contextual knowledge."

    The way that Zachary Rethorn, PT, DPT, looks at the interplay of all of these elements—cultural competence, efforts to diversify the physical therapy profession, consideration of social determinants of health and their role in exacerbating health disparities, and the broad effects of implicit bias in health—is this:

    "If all we're looking at is the patient in front of us—without respect to the environment within which that individual lives, grew up, and functions, and how that environment shapes that person's beliefs, culture, and attitudes—we miss the boat. We're not really treating the whole person."

    Human beings naturally like to think of themselves as nonjudgmental and bias-free, Rethorn notes. We like to think—we may even boast—that we treat everyone the same way. But there are 2 problems with that when it comes to physical therapy, Rethorn says. First, no PT or PTA—indeed, no one at all—is free of bias. Second, treating everyone the same isn't desirable, because that approach doesn't account for the different experiences and attitudes that each patient brings to physical therapy.

    Factoring in the social determinants of health, then, "provides a neutral framework to help explain some of the things a PT or PTA might otherwise attribute to a person's free will, when the reality is that there are systemic forces at play that must be taken into account," says Rethorn, a faculty development resident at Duke University and a board-certified clinical specialist in orthopaedic physical therapy.

    "The great thing about social determinants," he continues, "is that they allow you to put your own biases to the side, if you can, and instead ask the patient, 'How are conditions in your neighborhood shaping you? What about the built environment? Do you have access to public transportation? Is your community safe?' Because all of those things can produce health disparities that may, in turn, impact the plan of care," Rethorn says. "Or, rather, those elements should affect the plan of care—and how it's executed. If that's not happening, then we aren't doing our job very well."

    When he was fresh out of PT school in 2015, however, he wasn't thinking about any of those things.

    Rethorn, who is white, grew up in upper-middle-class neighborhoods among people who looked like him. As he puts it, "My lived experiences"—including the composition of his faculty and classmates in his DPT program—"did not produce much contact with people from other cultures or ethnicities." He adds, "I wouldn't have been able to tell you what a health disparity was when I graduated with my DPT. It wasn't discussed in the curriculum." After graduation, however, Rethorn found himself working at an outpatient clinic in a low-income area of Chattanooga, Tennessee, whose population was predominantly African American.

    It was far from a match made in heaven.

    "Absolutely I came in with biases of my own," Rethorn says now. "First, I'll concede that I had a hero complex when I started working there. I believed that I was going to fix people's pain and movement problems. I thought that I'd deserve my patients' thanks and praise for 'fixing' them."

    Such praise was not forthcoming. Most patients seemed wary of him. Some shunned him altogether.

    "I think I also held some unexamined biases against people in poverty and racial minorities," Rethorn reflects. "I definitely had patients who I strongly disliked for various reasons—their health behaviors, their attitudes, their beliefs, their presumptions. In fact, I spent much of my first year in practice with a counselor, working through the dichotomy of wanting to care well for my patients yet having these negative feelings. That's part of what drove me to better understand the community and the societal-level drivers of health there—which, in turn, helped me reframe my negative feelings."

    Also, Rethorn says, "another part of working through my unexamined biases came from my church. I attended a very ethnically diverse church and was able to build close friendships with people of color who grew up in the community that I served—people who had long histories and lived experiences with health care providers and other white folks in the area. My friends gently but firmly challenged and changed my understanding of my cultural biases and my expression of them. That was invaluable."

    One of the big things Rethorn learned upon looking into the clinic's history was that "not only did a lot of patients not trust me, but they had legitimate reasons for that." For example, "In the year before I started there, 14 clinicians came and went. PTs didn't want to be there because the high no-show rate among patients meant PTs couldn't get performance bonuses." But Rethorn could see the patients' perspective, as well: What incentivized them to show up, when they were likely to be seen by a new PT every time—or, at best, by a short-timer whose demeanor likely telegraphed ambivalence and an itch to leave?

    Rethorn gradually won over patients partly by just showing up—week after week, month after month. But that hardly was all he did. He asked his patients a lot of questions about themselves and their lived experiences—taking his church friends' advice to heart and striving literally to understand where people were coming from. He organized cookouts in the parking lot to which everyone in the community was invited. He took on an advocacy role, as well, working with the neighborhood association and city council to improve local sidewalks for better safety, utility, and recreation.

    He stayed at the clinic for 3 years and spent a few additional months as a home health PT in the same community. "One of my patients ended up telling me, 'For a white guy you're not so bad,'" Rethorn recounts with a laugh. "That was one of the best compliments I received during my time there."

    He continues to receive occasional phone calls and texts from his former patients in Chattanooga, seeking advice or just wanting to check in. Many tell him that things haven't been the same at the clinic since he left. His reaction to that is mixed.

    "It's gratifying to know I was of service and that I'm missed," Rethorn says. "But what I'd most like would be for the experience those patients had with me, despite our different origins and experiences, to be the rule rather than the exception across physical therapy."

    For her part, Marie Vazquez Morgan, PT, PhD, will never forget a patient who'd sustained a spinal cord injury from a gunshot wound. "He was wearing a blue bandana, which in that particular place suggested gang membership. That was my immediate assumption," she recalls. "It certainly explained the gunshot wound."

    To this day, Vazquez Morgan, now as associate professor in the Department of Rehab Sciences at LSU Health Shreveport in Louisiana, shudders to think what might have happened had her dialogue with the man and her body language toward him conveyed her bias—which at that point in her career she hadn't yet identified and examined—that, if that individual indeed was a gang member, he "probably didn't want to be there, wasn't going to be a good patient, and probably wouldn't adhere to the plan of care." Such signals "would have been detrimental to the PT-patient relationship and to goal-setting with that patient," she notes.

    Upon close questioning, however, she learned that her patient had been shot accidently by his cousin, simply liked to wear bandanas, and hoped to recover sufficiently to put his recently acquired master's degree to work. "Once I had the entire picture, he and I worked together to set the goals that were important to him," she says.

    Her takeaway, Vazquez Morgan says, was, "I had to do a better job of getting to know my patients. I needed to have some general understanding, at least, of the culture from which each person was coming. I needed to ask questions and not make assumptions. I needed to avoid stereotyping gang members, too. I had to 'individuate' everyone who I was going to be treating."

    Bernadette Williams-York, PT, MSPT, DSc—associate director of the Division of Physical Therapy at the University of Washington and vice chair of the Diversity, Equity, and Inclusion (DEI) consortium of the American Council of Academic Physical Therapy (ACAPT)—says, "As a person of color in a profession that's predominantly white, I've been in a number of situations in which my skin color has been perceived negatively. But we all have biases," she acknowledges. "I'm not exempt or excluded from that."

    To better identify and understand her biases, Williams-York has taken tests offered by Project Implicit, a nonprofit that seeks "to educate the public about hidden biases and to provide a virtual laboratory for collecting data on the internet."6 Subjects of the quizzes, known as Implicit Association Tests or IATs, run the gamut from race and ethnicity to gender, sexuality, religion, weight, and other matters.

    The results that surprised her most, Williams-York says, were from the test on disability.

    "I was like, 'Wow!' I had no idea I had biases there," she says. "But now that I know that, when I come into contact with individuals with disabilities, I am much more conscious of my interactions with them and more focused on preventing my implicit biases from coming out in way that could have a negative impact on them."

    Testing Self-Awareness

    In fact, Williams-York advocates that everyone involved in the physical therapy profession—from school admissions officials, to faculty, to students, to PTs and PTAs—take as many IATs as they can as an important step toward battling the health consequences of implicit bias in patient care. And the pervasiveness of bias and its potential effects are substantial, the research shows.

    Implicit bias is "generally consistent across studies, [which] suggests that clinicians have similar implicit biases to others in society."7 It is "significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes."8 It needs to be addressed in health care, although "more research in actual care settings and a greater homogeneity in methods employed to test implicit biases in health care is needed."9

    "The more IATs you take, the more you'll know about where your biases may lie," Williams-York says. "The tests are for self-knowledge and personal growth. What you learn from them will make you less likely to act on your biases and will help you be a better health care provider. Once we're aware of what our implicit biases are, we're going to be much more conscious of things like making appropriate eye contact, speaking in the proper tone of voice, sharing the best and latest information with patients in the most digestible way, and presenting the home exercise program in a manner that's easy to understand and complete."

    At the University of Washington, Williams-York notes, since 2015 students have been allotted class time to take the IAT on race and are encouraged to take other IATs, as well. Additionally, since 2017 members of the DPT program's admissions committee and faculty have been "strongly encouraged" to take the IAT test on race. Coincidentally, Williams-York reports, in recent years the number of the university's DPT students identifying as African American, Hispanic, Pacific Islander, and multiracial has risen. The proportion of Caucasian students has dropped from 71% in the class that entered the program in 2015 to 50% this fall.

    Although it's impossible to know how increased student diversity within the DPT program and enhanced student and faculty awareness of their implicit biases may affect the future clinical actions of University of Washington graduates, Williams-York reasons that the effects can't help but be positive.

    "I'm hoping that our emphasis on addressing bias and enhancing diversity will become a trend," she says, "and that other PT and PTA education programs will adopt these practices to confront implicit biases—and also to support APTA's ongoing efforts to increase the numbers of underrepresented minorities in the profession."

    To the latter point, Williams-York notes several initiatives that the association is undertaking. "Making APTA an inclusive organization that reflects the diversity of the society the profession serves" is among the association's strategic plan's goals and objectives for 2019-2021.10 APTA already has in place at least 25 policies related to diversity, equity, and inclusion, and the association annually awards scholarships to students from underrepresented minorities.11 In addition, APTA has backed pending congressional legislation to provide federally funded diversity-based scholarships and stipends.12  

    As Hadiya Green Guerrero, PT, DPT, sees it, "Tests like the IAT"—there are other tests of implicit bias, she notes, but IATs are the best known and most widely used—"bring your biases to the forefront of your awareness. They may confirm biases you suspected you had, or they may highlight biases you had no idea were so strong. Once you've taken the test, you have a reminder. The next time a related bias shows up, in whatever form, you'll be alert to zero in on it and try to mitigate any negative impact."

    Green Guerrero, a senior practice specialist at APTA, wrote a post on implicit bias for the association's #PTTransforms blog in 2016.13 In it, she noted that "We all possess biases that impact every interaction we have with our patients," and she presented illustrative examples of implicit bias in clinical practice. Green Guerrero concluded the piece by noting, "We may never rid ourselves completely of implicit bias, but we can be honest with ourselves and do whatever we can to see to it that our biases aren't making clinical decisions for us. Our patients—all of them—deserve that much."

    The Role of Educators

    Senobia Crawford, PT, PhD, directs the DPT program at Hampton University in Virginia. Recognition of the importance and value of diversity in physical therapy is inherent in Hampton's mission as a historically black college, but Crawford laments the overall pace of progress. The profession (as reflected in APTA membership), its educational pipelines, and its student enrollments remain overwhelmingly white.3,14-16 And that, Crawford says, abets inherent bias by ensuring that fewer PTs and PTAs will share the lived experiences of the diverse patient mix they serve—and that patients, in turn, will encounter fewer PTs and PTAs who might best understand their concerns and enhance their comfort level and trust in the care they receive.

    Crawford chairs ACAPT's DEI consortium. She would like to see, in particular, implementation of the recommendations of the academy's Diversity Task Force, on which Williams-York served. That panel's report17 issued in 2016, urged in part, that:

    • Physical therapy be better promoted as a viable career option for students from underrepresented minorities (URM),
    • A new pre-DPT admissions structure be created to simplify standards and prerequisites across programs,
    • PT education programs explore "new and creative avenues" to provide URM students with greater financial assistance,
    • APTA and its Student Assembly team up to "reinvent" a mentoring network matching URM professionals with URM students, and URM students with URM prospective students, and
    • Schools pool their URM data and "prioritize a research agenda to further understand factors and provide evidence to support URM student choice of a physical therapist career."

    Such efforts are vital, Crawford says, because, "When you talk about different issues in class and have people from many different backgrounds participating in the conversation, the dialogue is much richer than it would be if everyone's experiences were similar." Such dialogue, she adds, "presents a great opportunity for growth, learning, and change."

    PTs interviewed for this article cite a variety of ways in which PT and PTA education programs can and in many cases do inculcate bias awareness in students and seek to familiarize them with the lived experiences of people who may be unlike themselves. Such activities range from incorporating diversity elements and details related to social determinants of health into case scenarios discussed in class, to ensuring student participation in community health fairs, pro bono clinics, and career days for youth.

    All of the PTs interviewed agree, however, that much work remains to be done. Green Guerrero notes that when she attended APTA's National Student Conclave last year, "students were coming up to me and telling me their teachers 'just don't get it'—they're doing a poor job of incorporating bias awareness into the curriculum, and of preparing students to face their own implicit biases and the biases they may encounter in clinical practice." (For more on the latter subject, see "When You're the Target" on this page.)

    The Power of Exposure

    "Knowing your own biases is nothing without exposing yourself," Green Guerrero says. That's why she encourages PTs and PTAs to seek opportunities in both their professional and personal lives to interact with people whose racial characteristics, ethnic background, socioeconomic status, gender role, religion, body type, or what have you differ from their own.

    "If you feel uneasy around black people or Muslims, for instance, volunteer to work in a pro bono clinic, or seek work at a hospital or health center that serves people who are underserved and/or disenfranchised," Green Guerrero advises. "Do your best to think about your biases and check them at the door. Seek to learn and understand what brought each patient or client to the clinic, what constitutes his or her biggest health concerns, and what barriers that person faces to optimal well-being and needed interaction with the health care system."

    "Similarly," she continues, "instead of giving money or footwear to Shoes 4 Kids—or in addition to it—be part of that event at Annual Conference. Meet the kids who need the shoes and are thrilled to be receiving them. You'll gain a little insight into their family life and economic circumstances. You'll experience emotional uplift, for sure, but you'll also add awareness and sensitivity that will help you be a better PT or PTA moving forward."

    Opportunities abound, Green Guerrero notes, to serve others while learning more about them—and, in the process, to educate oneself. "How about working with the Special Olympics, or with local events that give people with disabilities opportunities to enjoy the fruits of athletic competition?" she asks. "Any biases you might have toward that population are bound to be challenged by your exposure. It's easy to stereotype what you don't know, but it's much harder to reconcile your unchallenged beliefs with the skills, determination, and effort you're experiencing with your own senses."

    Unchallenged biases threaten to become "isms," observes Johnette Meadows, PT, MS, director of minority and women's initiatives in APTA's Department of Practice—racism, sexism, et cetera. When that happens, "You're a complete failure as a professional," she says. "If you don't make every effort to respect an individual by taking a thorough patient history, then working with that person to develop goals that are specific to his or her circumstances and needs, you have wasted that patient's time. If you let your biases interfere with how you're supposed to be performing your duties, it's a big problem. You're helping to perpetuate the health disparities that unfortunately are so evident in health care today."

    Eric Ries is the associate editor of PT in Motion.

    References

    1. Wojciechowski M. Who are tomorrow's PTs and PTAs? PT in Motion. 2018;10(5):30-41.
    2. Lehmann C. Addressing social determinants of health. PT in Motion. 2019;11(6):28-39.
    3. Office of Disease Prevention and Health Promotion. Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed July 19, 2019.
    4. Bullen Love D. Recruiting tomorrow's PTs and PTAs. PT in Motion. 2019;11(7):18-25.
    5. The Joint Commission. Implicit Bias in Health Care. www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf. Accessed July 17, 2019.
    6. Project Implicit. https://implicit.harvard.edu/implicit/. Accessed July 17, 2019.
    7. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we do from here? Perm J. 2011;15(2):71-78
    8. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12)e60-e76.
    9. FitzGerald C, Hurst S. Impicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
    10. American Physical Therapy Association. 2019-2021 Strategic Plan. http://www.apta.org/StrategicPlan/Plan/. Accessed July 17, 2019.
    11. American Physical Therapy Association. Minority Scholarship Award. http://www.apta.org/HonorsandAwards/Scholarships/MinorityScholarship/. Accessed July 17, 2019.
    12. American Physical Therapy Association. PT in Motion News. APTA-Backed Bill to Provide Diversity-Based Scholarships, Stipends Introduced in House. http://www.apta.org/PTinMotion/News/2019/07/10/WorkforceDiversityActIntroduced/. Accessed July 17, 2019.
    13. Guerrero HG. Sneaky bias: what you don't know may hurt you (and your patients). American Physical Therapy Association #PT Transforms blog. July 20. 2016. http://www.apta.org/Blogs/PTTransforms/2016/7/20/SneakyBias/. Accessed July 17, 2019.
    14. American Physical Therapy Association. Physical Therapy Workforce Data. http://www.apta.org/WorkforceData/. Accessed July 17, 2019.
    15. Commission on Accreditation in Physical Therapy Education. Aggregate Program Data, 2018-2019 Physical Therapist Education Programs. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/AggregateProgramData_PTPrograms.pdf. Accessed July 17, 2019.
    16. Commission on Accreditation in Physical Therapy Education. Aggregate Program Data, 2018-2019 Physical Therapist Assistant Education Programs. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/AggregateProgramData_PTAPrograms.pdf. Accessed July 17, 2019.
    17. American Council of Academic Physical Therapy. Report of Diversity Task Force, January 4, 2016. https://acapt.org/docs/default-source/reports/diversity-task-force-final-report.pdf?sfvrsn=6249b3d8_2. Accessed July 17, 2019.

    When You're the Target

    Given that everyone has implicit biases, PTs and PTAs often are on the receiving end of them—from both patients and peers.

    Having grown up and begun her physical therapy career in South Africa, Thubi H.A. Kolobe, PT, PhD, FAPTA, had a lot of experience with bias before she came to the United States in 1978. That, however, was explicit bias under apartheid, the government's policy of racial segregation and economic and political discrimination. In South Africa, Kolobe, who is black, worked in a 1,200-bed hospital that served black patients only. Of the facility's 14 PTs, she alone was nonwhite.

    A lot has changed in South Africa since then. In the United States, where bias against both practitioners and patients of color tends to be implicit, unconscious, or hidden—Kolobe calls it "bias with kid gloves"—much still needs changing, she says, more than 40 years after her arrival.

    "Implicit bias excludes you from the table," Kolobe says. "And, since the table is where decisions are made that impact people, implicit bias engenders stress and anger in those who bear its brunt."

    She's 1 of 2 faculty members of color in the 18-member Department of Rehabilitation Sciences at the University of Oklahoma Health Sciences Center, where she's a professor and the director of research. Kolobe has read the statistics and seen with her own eyes the lack of diversity, compared with the overall population, among PT and PTA faculty and students, and among PTs and PTAs in the field. A researcher herself (in pediatrics), she's well-versed in the literature linking health care biases, inadequate diversity, and health disparities among underserved populations.

    Even now, Kolobe says, she's sometimes talked around in meetings and roundtable discussions by white speakers who don't make eye contact with her. She attends professional conferences at which sessions on diversity ironically lack diverse panelists.

    Her proposed solutions start with the "low-hanging fruit" of ensuring that diversity- and social determinants of health-related elements (which reflect implicit biases) are incorporated into the case scenarios presented to PT and PTA students. Similarly, she says, continuing education courses and workshops for PTs and PTAs need to explicitly include diversity-related case scenarios and address implicit bias.

    From there, Kolobe advocates that APTA and the Foundation for Physical Therapy Research join forces to seek out and fund innovative model programs to better educate students and clinicians about the value of diversity and the dangers of inherent bias. She urges that lessons culled from those programs, then, be broadly disseminated throughout the physical therapy profession.

    Hadiya Green Guerrero, PT, DPT, who also is black, began encountering implicit bias very early in her professional journey, when she and several white DPT-student classmates entered a patient's hospital room dressed identically, but the white patient assumed Guerrero was maintenance staff and asked her to take out the trash.

    When she was working at the Mayo Clinic in Minnesota, in a couple of instances children described Green Guerrero as "dirty" because of her skin color—reflecting societal or parental biases. Another time, the father of a nonverbal patient tried to project onto his son fears of working with a black female PT that the parent himself clearly harbored.

    "These are teachable moments," Green Guerrero says. "The beautiful thing about kids is that they operate with their id but they're usually very-open minded. I explained that I'm not dirty, just brown. I put my arm next to theirs and we compared. It didn't come up again."

    Green Guerrero doesn't kid herself that she vanquished the racial biases of the father of the nonverbal child. "But I did gain his trust in the way that I handled his son," she says. In that particular instance, she not only exhibited strength of character by keeping things professional, but also physical strength that impressed the dad.

    "I've power-lifted since I was 14 years old," she says. "The patient was a big kid who'd undergone spinal realignment surgery, but I was able to handle him safely and effectively." At one point, Green Guerrero overheard the father describe her on the phone as being "like Superman."

    Like Green Guerrero, Marie Vazquez Morgan, PT, PhD, and Bhupinder Singh, PT, PhD, have experienced their share of "teachable moments" with patients and colleagues. Vazquez Morgan came to the United States at age 5 from Argentina. Singh, who's from India, is a Sikh who sports a full beard and wears a turban. He's an associate professor in the Department of Physical Therapy at California State University, Fresno. Most instances of bias have been rather benign, they say—such as Vazquez Morgan fielding incorrect assumptions that she's from a large family because she's Hispanic.

    But there have been a handful of times in his career, Singh says, when he has determined, "This person is too hung up on my looks and religion for us to be able to work effectively together." In such cases, he says, "I think it's my job as a health care professional to leave my ego out and refer that individual to a therapist who can better ensure the person gets the care that's needed."

    "But I always try to take the conversation in a positive way," Singh adds. "I don't complain and say, 'I am of the Sikh religion, and I came to this country after 9-11, so stop stereotyping me.' I'm happy to talk about my background if people ask, and we then can move on to focus on the patient's needs."

    Matt Huey, PT, MPT, also has faced bias based on his physical appearance. But he's not a member of a racial, ethnic, religious, or gender-based minority. The way he dresses doesn't attract undue attention. He's simply a big, buff guy.

    "I'm, like, 6-1 and 225 pounds," Huey says. "I weightlift and run. So, I have a very muscular build. I also have a goatee. My wife has told me, "'You have this resting angry face.' But I'm not angry. That's just how I look."

    Certain patients—older women especially—find Huey intimidating, he says.

    "They're reserved around me," he says. "Nervous, timid. Short answers, lack of eye contact. They think I'd going to hurt them."

    The potential for a suboptimal PT-patient relationship—and subpar care results—are heightened in such situations. But Huey employs a number of strategies to win over wary patients. They're things that all PTs should do, but the issues related to Huey's size remind him to be diligent.

    He addresses that "resting angry face" thing by taking care to smile and do everything he can to appear unthreatening. He's "very engaged" with his patients, making clear that he wants to know as much about their health issues and concerns as they're willing to share—and that he's there to help. He makes certain that patients know in advance every move he's about to make—and why he's going to make it. And he proactively talks about pain—why the individual is experiencing it, what's needed to best address it, and, perhaps most important, that there's absolutely nothing to be gained by his doing anything to exacerbate their pain.

    Typically, Huey says, "patients who were clearly fearful of me come out of that first session feeling much more comfortable and ready for us to work together. They go from sometimes flat-out saying 'You're going to hurt me!' to telling me, 'Matt, you are the gentlest person.'"

    Resources

    APTA

    Cultural Competence in Physical Therapy

    www.apta.org/CulturalCompetence/

    Racial and Ethics Health Disparities

    www.apta.org/HealthCareDisparities/

    Other

    Project Implicit—Take an Implicit Association Test

    https://implicit.harvard.edu/implicit/takeatest.html

    Equality of Care

    www.equityofcare.org/

    Institute of Diversity and Health Equity

    www.diversityconnection.org/


    Comments

    Excellent article. I am a PT with a rare form of midlife Muscular Dystrophy and use a power chair primarily when out. I find I am often discounted solely by being in my power chair.
    Posted by Dianne Davidson on 9/30/2019 7:53:21 PM
    Social engineering and programming is a fascinating subject. I'd like to see more of how the tribe/herd can be moved into action in the desired direction by a well designed propaganda campaign using our base instinct of needing to be accepted and admired by patients and peers. Integration of this discussion with uncertainty heuristics and biases, rational choice theory, ecological rationality, etc. would be illuminating as well. In a related area, the exploration of the topic of economic shock testing, as discussed in the document "Silent Weapons for Quiet Wars", may be apropos considering the 8% CMS pay cut we are potentially facing. These are exciting and challenging times in our profession.
    Posted by Brian Miller on 9/30/2019 9:48:50 PM
    Thank you for this article! Excellent dialogue starter...
    Posted by Olabisi Brown on 10/8/2019 8:46:46 AM
    Great article. I think there's an opportunity for the pendulum to swing too heavy in either direction. While practicing in an affluent area, there remain opportunities for students and new clinicans to hone their skills in Cultural Competence. While treating well educated and generally informed patients, there are often challenging situations surrounding 'best practice'. A patient may arrive requesting the latest and greatest treatment approach; needling, cupping or antiquated modalities of ultrasound and the like. There is a tightrope to navigate to share what our CPGs have to offer, where the current evidence is, all while building rapport necessary for patient compliance and confidence in care. These conversations require knowledge of the trends as well as foundational evidence and blending those into meaningful dialogue with a patient. Simply condoning unproven treatments perpetuates the problem plaguing our field and promotes patient driven versus patient-focused care. Matt Calendrillo PT, DPT, BOCOP LIVE EVERY DAY A Physical Therapy Co. Simsbury, Suffield, Avon CT, Springfield MA
    Posted by Matt Calendrillo on 10/10/2019 3:31:23 PM

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