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Intentional or not, small slights have a large impact.

In this podcast, APTA Ethics and Judicial Committee member Becca Edgeworth Ditwiler, PT, DPT, interviews Keshrie Naidoo, PT, DPT, EdD, Julian Magee, PT, DPT, ATC, Karla Bell, PT, DPT, PhD, and Debra Gorman-Badar, PT, PhD, about the damaging effects of microaggressions and ways to address them.

Read "Ethics in Practice: Small Slights, Big Lessons" in APTA Magazine to learn more about microaggressions in physical therapy.

Our Speakers

Rebecca Edgeworth Ditwiler, PT, DPT, board-certified orthopaedic clinical specialist, is a member of the APTA Ethics and Judicial Committee. She is an associate professor and practicing PT for the University of South Florida's School of Physical Therapy and Rehabilitation Sciences at the USF Health Morsani College of Medicine in Tampa.

Keshrie Naidoo, PT, DPT, EdD, is interim chair and an associate professor in the Physical Therapy Department at the MGH Institute of Health Professions. She is also the director of the MGH Institute Clinical Residency in Orthopaedic Physical Therapy and editor-in-chief of the Journal of Physical Therapy Education.

Julian Magee, PT, DPT, ATC, is the inaugural assistant director of diversity, equity, and inclusion for the Program in Physical Therapy at Washington University School of Medicine in St. Louis. His accomplishments were recognized when the program earned APTA's 2022 Minority Initiatives Award.

Karla Bell, PT, DPT, PhD, is an associate professor of physical therapy in the Jefferson College of Rehabilitation Sciences and in the College of Nursing at Thomas Jefferson University in Philadelphia. She also is a member of APTA's DEI Committee and was founding co-chair of PT Proud in the APTA Academy of Leadership and Innovation.

Debra Gorman-Badar, PT, PhD, is a clinician and health care ethics consultant. She serves on the APTA Ethics and Judicial Committee and as the Ethics Liaison for APTA Montana.

The following transcript was created using artificial intelligence and may contain typos, omissions, or other errors.

Becca: Welcome to this APTA podcast episode centered around microaggressions and physical therapy. I'm Becca Dittweiler and I will serve as your host for this podcast. I'm also representative of the Ethics and Judicial Committee, bringing current ethical issues to wherever you hear your podcasts.

I have a really dynamic group of individuals here with me today with varying interest and expertise in this topic, and I would like to welcome Keshrie Naidoo, Julian McGee, Karla Bell, and Debra Gorman-Bader. Thank you so much for joining us today for this podcast. And in case you aren't familiar with this amazing staff of people, Keshrie Naidu is the interim chair and associate professor at M.G.H. Institute of Health Professions, and Keshrie is the current editor in chief at the Journal of Physical Therapy Education, amongst many other scholarly endeavors.

Julian McGee is the assistant director of diversity equity and inclusion for the PT program at Washington University in St. Louis. Julian has made significant impacts in his role throughout the academic community. Karla Bell is an associate professor at Jefferson College of Rehabilitation Sciences and was the co-founding chair of PT Proud. Karla currently serves on APTA's DEI Committee. And Debra Gorman-Bader is my colleague on the Ethics and Judicial Committee who has a PhD in health care ethics. Debra, along with Karla and myself, co-authored the May issue of the Ethics in Practice column, addressing microaggressions. So please check it out. One of the main goals of this podcast is to raise awareness about microaggressions in physical therapy and give ideas for what to do if you experience, witness, or commit a microaggression. Karla, can you start by explaining some of the basic definitions around microaggression or different types of insults that might be committed?

Karla: Sure, thanks for the question. So, microaggressions are subtle, unintentional acts or comments that convey negative stereotypes or biases, right, toward marginalized individuals typically. And what these slights or insults can do is they impact a person's well-being and sense of identity. They're typically in the literature or three main types of microaggressions. One is micro-insults, and those are unintentional but discriminatory remarks or behaviors. And so an example of that might be something like telling someone that they're maybe articulate, quote, quote, "because of their race." And the impact of that is it really undermines a person's identity or experiences.

Then there are what we call micro-assaults, and these are typically maybe intentional and overt discriminatory actions or comments. So something like using racial slurs or maybe offensive jokes. And those are directly harmful, right? The targeted individual.

 And then we have things called micro-invalidations. And those things are dismissing or invalidating someone's experiences or feelings. So saying something like, well, I don't see color, or we're all equal. And that negates the impact of discrimination and denies lived experiences.

And so these are three types of microaggressions.

And microaggressions, they manifest in various ways. So they manifest in ways like minimizing cultural experiences. So maybe dismissing or downplaying someone's cultural backgrounds or experiences. They also manifest like pathologizing cultural values and collectivism. So maybe treating cultural practices as abnormal or problematic. And then we have things like over-identification, where assuming that all members of a particular group share the same experiences or characteristics. And so those are just a few ways that microaggressions manifest.

Becca: Thanks, Karla. I really appreciate that. And one of my questions is, how common do you think that those experiences are in our profession? Whether that's on the professional side or the patient side? Do you think this is happening a lot?

Karla: I personally, and through there's been some literature that has come out, specifically related to underrepresented minorities or marginalized individuals in the physical therapy profession, both clinically and in students, that actually speak to this area. And it speaks to the fact that this is happening more than probably people want to admit or people maybe even know. And so, and I'm sure other folks will speak to some of these experiences, but from personal experiences, working with students in the field and also working clinically, I would say that these have been observed by myself on an everyday basis, unfortunately.

Becca: Julian, do you have other thoughts or examples or things that you might share, your experiences or your students' experiences?

Julian: I would agree with Karla in saying that this is, you know, every day, every hour, I mean, it may not be the same individual, but they're happening far too frequently to be able to count, and which is a problem. It's a problem if it happens once. It definitely becomes a problem with the frequency. And often, how it is overlooked. So it's one thing to experience a microaggression, but then when you go into the point, you experience it, you feel it, and then you have the invalidation piece on top of it.

I think in my experience when I have had these moments, the things that have hurt the most have definitely been the invalidation. I don't need you to understand it to hear me and see me and give me that piece of humanity. I often hear from people is that sometimes it's like I have to be superhuman in my response; I don't get to be upset about it. Because then it becomes another micro-assault or a micro-invalidation. What they just said is you shouldn't be so sensitive to someone's words. It's different types of things that you see that are perpetuated over and over again. And then when you think of the work of Geronimus in "Weathering" ["Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society" by Arline T. Geronimus], it's no wonder that we sometimes see the health outcomes that we do when people live in the systems perpetually.

Becca: Keshrie, what are your thoughts?

Keshrie: Yeah, so I agree with both my both my colleagues, when Karla had described microaggressions and talked about them as being like subtle and layered. Sometimes when you hear one type of microaggression, like a common one that our students of color will often hear is, where are you from? And it seems like, oh, it's so harmless. Somebody just wants to get to know you, a patient is just interested in you. But then the question is, do they ask every physical therapist student that? And is the question then, when the student answers, "Oh, I'm from California," is it followed up with, "No, but where are you from really," right? And then the thing about microaggressions is that they compound. So it's not just that this just happened with this one patient, it's that it happens with subsequent patients, and then it sends the message to the student that you don't belong here, not just here in the state, but you don't belong to this profession. Surely somebody like you can't be, you know, getting ready to be a doctor of physical therapy.

So when we talk about the health effects of it, we're thinking about the compound effects. And that's why you'll hear that sometimes some authors, like, Kendi ["How to Be an Antiracist" by Ibram X. Kendi], don't like the term micro-aggressions because they feel like it's not micro. Right? And language is beautiful and always evolving. And I've heard it referred to as identity-related aggressions; in this great book that I'm reading called "Did That Just Happen?" by [Stephanie] Pinder-Amaker and Lauren Wadsworth, because that is what the microaggression feels like. You almost don't realize it in the moment. But then later that night, or when you're talking about it to someone, like, "Did that just happen? Did they just assume that I was a member of the custodial staff, even though I was wearing a white coat, and I had this stethoscope?

And so I think it can be dismissed if one person sees it one time, but when we're talking about marginalized identities and the intersection of marginalized identity, and where you fall in the hierarchical model of the health care system, it's ubiquitous. It's everywhere.

Becca: Yeah, so far I've really enjoyed the examples that it really brings to life this issue. What I want to know is how do you think this affects patients? So I definitely think we've talked about students, we've talked about providers. How does this trickle down? I think Julian talked about a little bit with the thinking larger. I'd love to spend a little more time talking about that. How does this affect patients and our health care system and what are the potential outcomes from that?

Julian: From a patient perspective, I think it limits access to providers who they can identify with. That's the first thing. It's hard for me to want to be in a place to give my best to take care of individuals when I feel threatened. And that's anything. If I have to think about running into a building on fire. I have to have a vested interest to do that. And if I have to go into a place that I'm going to be attacked daily, I have to prep myself for that. I can choose to go somewhere else where I'm more valued. And so that may allow the opportunity to not have patients to receive the kind of care that they want, or it may lead to an overburdening of care as well.

So I've worked in places where I would often be the only one, the only Black male or only African American in the building. And so I would see patients and they would see how I'm working with everyone, and then well I want you to work with me. So there's another person I want you to work with me and I have to tell them no. So again, there is this burden of I have to take on all of everyone's patient care, especially these people who look like me, because they don't feel like they're getting that, or I have to put this burden on myself to be able to go through and weather the storms are the same just to be able to do my job.

And what I always say is, if I have to spend 1% of my time throughout the day thinking about the ramifications of my identity in a place, well that's 1% less of time that I can dedicate to patient care because consciously or unconsciously I still have to think about how am I going to react or not react when this happens. And it's not as if, it's a when.

Becca: Go ahead, Debra.

Debra: I think so far we've been talking about microaggressions towards physical therapists, but in the big picture of microaggressions in health care, microaggressions happen at multiple levels. And I think we have to remember that. There's good research that shows microaggressions happen at multiple levels. And I think we have to remember that. There's good research that shows microaggressions from health care providers towards patients, which definitely affects patient care. Patients, why would a patient want to come back for physical therapy services when they have been treated that way? But we also see subtle microaggressions between health care providers, colleagues, within administration and providers. I mean, it can happen at all levels, and we have to be really cognizant of that aspect of microaggressions as well.

Becca: Yeah, thanks, Debra. Karla, what are your thoughts?

Karla: Yeah, and thank you for that. So I was going to say something similar to Debra about the fact that we're talking about, as it manifests with patients, health care disparity. So some of the things that go, health care disparity speaks to the quality oftentimes that is different. The quality of care that some patients get is different than others. And a lot of times that is because of these micro- and some macro-aggressions and outright discrimination and bias. And I think of the role that microaggressions plays in that, in my concentration in my research in population health, is with sexual and gender diverse individuals.

And I think about the literature, the rich literature that surrounds the fact that patients are micro-aggressed every single day in their health care experiences in a variety of ways, invalidated, right? Micro assaults, right? Because of who they are and nothing else. And that is really something that we all need to speak to in this profession of health care when we are the helping profession, and the patient in front of us has unique needs because of who they are, and we need to give them the care that they want and treat them respectfully regardless of whether we understand everything regardless of what we believe. Because at the end of the day, patient-centered care is about them and where we meet them and their needs and their cultural needs and not about us at all, right? Yeah.

Becca: Debra, I'm wondering if you can, as we're talking about the fact that we, if we're looking at ourselves, and talking about our impact in health care, are there ethical principles we should consider as it relates to the way that we're interacting with patients around some of the things that Karla was just talking about, related to how your expectations, how we consider their culture, or what are some other things that we should be considering from an ethical lens?

Debra: I think the most important thing about ethics is to understand that ethics is about our relationships with others. And as health care providers, we have a responsibility to build those relationships, whether they're with our patients, with our colleagues, with our administrators, within our profession, we have a responsibility to build relationships. And so, to me, the biggest problem with microaggressions is that they limit relationships. They destroy relationships. They do not do that. They do not build relationships. Certainly it's hard when you're the physical therapist being microaggressed, but it's important to step back and say, "How can I handle this in a way that builds relationships?"

My saying that doesn't preclude the possibility that some relationships should not be maintained, because there's always that thought. If there is so much conflict, then probably the best thing for the patient and the therapist is not to continue a relationship. But there's lots we can do in between to try to remember to build those relationships.

Becca: Thanks, Debra. Keshrie, what are your thoughts?

Keshrie: So I certainly agree about patient-centered care and us trying to prioritize — it's not all about me — but when I think about Debra's point about relationships, I think about the onus is on both people in the relationship to treat each other with dignity and respect. And I think to some extent some of the problems that we get into with "the patient is always right" is that we then promote a culture where a patient may not treat a health care provider from a marginalized or minoritized background with respect, right?

And so one of the things I always recommend is that students know the code of conduct of whatever space they're going to go into, because they'll see that absolutely we have our code of conduct as health care providers but so do patients and their family members and their visitors. And it's up to us to establish these norms for how we treat each other with respect so that we can build the profession that we want and move away from something that was "OK, the patient is always right; there's a level of disrespect that we are just going to tolerate." And then we create a culture where providers of color are not welcome and don't want to remain in the profession because it's a daily struggle and it's a fight.

So we can improve patient care by normalizing that their suspect is bidirectional.

Becca: Yeah, I think you bring up a really good point about provider rights and the rights to having a safe workplace where you feel comfortable, and you can engage in a way that's fair. I think that's a really important piece, and you, Keshrie, I really love the point about looking at organizations as well and knowing what are the policies that are in place that protect providers and patients, right? Both ends, because I think this definitely, like we said, happens in both directions, but I'm curious if any of you have thoughts about ways to build organizational support around some of these initiatives and how can that be fostered and more universal? Because in my experience, it seems pretty clear that some organizations are very forward thinking and very positive and supportive, and others don't acknowledge this exists at all. So are there suggestions that any of you have related to building some of that organizational support?

Keshrie: So I'll say that the first thing is to do what we've been talking about, which is normalizing it. These types of things happen. And here's how we deal with them at our institution, right? Whether it's the provider who commits the microaggression or whether it's the patient, or the family member, here's the code of conduct. Here's some scripting guidelines. Because when these things do happen in the moment, it can be so hurtful and shocking that you actually don't respond. And then you're thinking about it later when you're home and your family, like, ah, I should have said. So I think simple scripting guidelines help to provide respectful comments and guidelines. And we set a standard for the relationship, and that's how we build strong relationships, not by allowing somebody to behave a certain way.

I certainly appreciate that the patient is often, when we are interacting with the patient, they are having the worst day that they could possibly have, right? And this is not maybe how they would normally conduct themselves. I appreciate that 100%, but I also think that unless we say how we expect to be treated, we then can't expect the patient to do that. So like setting boundaries and then giving the patient the opportunity to change their behavior. And then we recover our relationship, and we can go on to have a productive working relationship.

Becca: It's a great point, Keshrie.

Debra: I would also say that in our upcoming ethics and practice column, Becca and I cite some intervention strategy strategies by Sue et al. ["Disarming Racial Microaggressions: Microintervention Strategies for Targets, White Allies, and Bystanders" by Derald Wing Sue, et al.]. And those to me, they actually give a table, and the table is very helpful, to deal with microaggressions at the individual and the organizational or institutional realm and also more microaggressions at the societal level. That would be a good resource for people who are trying to deal within their organization.

Becca: Karla, do you have anything to add about organizational pieces or perhaps some individuals can respond, you know, if they experience or perhaps commit a microaggression, maybe you could comment on that a little bit too.

Karla: Yeah, and I think the really key piece here is we need to normalize allyship and we need to normalize speaking up. Because the old adage of "sticks and stones" is the exact opposite of the message that we want to be sending in terms of being kind human beings with each other, right? The literature is extremely rich to say that "sticks and stones" is not true, right? That sticks and stones actually do hurt; words matter and the cumulative effect of these microaggressions have incredible manifestations mentally and physically on health.

And so I can say that the leadership of organizations really need to take a visible stance on, and I'm going to say the magic words, DEIB, right? Although we see a movement for anti-DEI initiatives across this country, which is scary when it comes when we're talking about the topics of health and well-being, right? And the fact that we're talking about microaggressions, and then we're talking about the manifestations of those microaggressions. And so the leadership and organizations really need to step up and provide role modeling in the fact that this is not acceptable, and trainings and education, cultural trainings, and also model how we treat each other and model how you speak up to somebody that if a microaggression is committed.

So if I'm working with a colleague, right, or somebody says something, they may, again, go back to the definition of microaggression, right? Oftentimes it's unintentional, right? They don't, they're not intending for that to sit how it sits with the receiver. It doesn't matter. The impact is still the same. So it still needs to be, then, turned around to the person who microaggrassed and say, "Hey, ouch, right? That actually hurt." Or, "Hey, I'm not sure if you understand how that came across." Or, "Hey, actually, that is not true." And state a fact. So there's a number of different ways that we can do that completely professionally, respectfully. Maybe if you don't want to do it in front of people, pull the person aside, right? But our responsibility is to make sure we follow through if we see or hear a microaggression and be that ally, right?

Becca: Thanks for sharing, Karla.

Debra: I think along those same lines is the idea of microaffirmations, which some psychologists have been putting forward, to sort of counterbalance the bad effects of microaggressions on people. And that can be done at all kinds of levels. We can do it with our colleagues. When we hear something happen, we can just affirm that they are a valued member in our department and on our staff. But that can also come from an organizational level, I think, as well, that the organization just has clear guidelines that every person is a value to the organization, and every person matters, and every person's input matters and their contribution matters to make it an organization work well to deliver good patient care. We're talking mostly about patient care, but it also goes to a good educational program or good administration. It really involves all the rules that the APTA identifies for our profession.

Julian: And can I just add, you know, the microaffirmation is a great thing, but I think with that, it comes from more than words, it's action. I have to see it put in place. You can say these things. And I think, and I only bring this up because oftentimes after these microaggressions, we usually hear those things, oh, you're such a valued member. Oh, we love you having you here, but I need you to show me, and not just tell me. I need you to do something to address the harm, and I don't need you to wait. I need you to say, well, we can, when you take your break, we can allow this patient who came in, who did that, that can then be, you don't have to be in the same room with them. That's not really the, it is, it is again, seeing, hearing and valuing my experiences and me. And to do that, I think it's not just the word, it's also the actions that go with it.

Becca: I think, well, this is great awareness. And I have a feeling that some people listening might think, maybe I've done that myself. And I know I have. And I've committed a microaggression unintentionally, like Karla and mentioned. So what are some ways that if we realize that this has happened, and we've caused harm to another person, and it was unintentional? How can we respond in a way that's caring? A caring response in a way that's appropriate and not defensive, like Julian talked about. How can we have that dialogue? Do you have suggestions that are practical that could help people?

Keshrie: So I think one is to remember that these are usually based on cognitive biases, right? That there's something that we have been conditioned to that has led us to respond in a certain manner and that we all have them. So that's the one thing. The other thing is that if we have caused harm, that we apologize, we don't focus on the intent. We know it wasn't our intent, but that doesn't help the person that I've you know committed this microaggression. So I focus on the impact. I apologize for the impact of my words on you, and this is how I'm committed to change and change is hard for human beings, but it can be done and then and then we do the work.

I think when I think about the apologies, oftentimes the microaggression is like, you know, public forum, but then sometimes the apology is private. And I feel that if it was, you know, some public shaming, and then, you know, it should be a public apology, too. But obviously, you know, if it's a one on one incident, then then you apologize and commit to change.

Becca: And, Keshrie, I think you're also bringing up the point about building culture of, like, that this is the thing that we know this happens and we want to model that this is something that we can also embrace and move forward and learn, right? In a larger group setting and a culture building.

Keshrie: Absolutely, and I think the opportunity for folks, patients, students, the clinicians who've experienced these microaggressions, the opportunity for them to debrief about it with their colleagues and to share what the impact on them was, I think is also very helpful because it helps them to not internalize this. You know, the things that we are talking about that are hurtful and compound over time, we don't want them to carry this burden alone. We want them to share it so that we're all committed to change.

Becca: It's great. Karla, do you have any other thoughts or other ways that you maybe have helped people to respond or kind of debrief like Keshrie was discussing?

Karla: Yeah, I mean, I obviously I completely agree with Keshrie, it's the apology that is the much needed part, right? The recognition apology, not making it about your intent, again because it's not about you. You just caused harm in a way that even if you didn't realize you did it, it still happened. And that I think is the hardest part for people. We have a tendency to want them to convey that we didn't mean it, right? And in this area of research and behavior and human behavior, we have to get away from that, because we know very well that the impact is what matters. And the impact was on that other person. And so let's make it framed around that other person and trying to acknowledge that we made that mistake or we made that insult, or however it came across, regardless of whether we intended it or not, and let's make it about them.

And I think there are ways, there are strategies depending on the context and the environment that it happens within. And so there's trainings out there, like one's called "Ouch, that stereotype hurts" or whatever, right? Like you can use little ways to interject and change the trajectory of what's going on. So if you happen to be observing the microaggression, you can just stop that person in the tracks as soon as they say something or by interjecting as an ally and going, "Ouch, that didn't really sit well. Let's change the topic." Or, you know, you can deflect, or you can be direct. So depending on the context, it's hard to give a situational exact answer here, but depending on the context and the situation in which it happens, there are different strategies that you should practice because unless we practice these things, they don't come very easily. And so those are the things that I suggest. Yeah.

Debra: Like Karla said, there's lots of different ways, but what she's really saying is you're trying to maintain some relationship. You're trying to build that relationship in a way that's positive, not just by ignoring what was said and internalizing it, not by agreeing with it, of course, but just by somehow still deal with the situation in a positive way that maintains and builds that relationship.

And I think that's sometimes really hard to do for all of us when we feel like someone has insulted us or assaulted us, microaggressions. But it can be done and it's a skill and it's a communication skill and it's a social skill that practice and trainings may really help with.

Julian: Yeah, I think one of the opportunities that we can do is when we have our team meetings, when we have our clinical meetings, is, are we bringing these things into play? We always think about, again, taking it back to patient care, well, what new technique can I do? What new things can I do? And one of the things that I see, especially when we can look at the context of students, it's usually not that they have had some major safety issue that's going to create issues in the clinical setting. It's because there's been some, to borrow Debra's term, you know, that relationship or breakdown in a relationship. They didn't communicate well, they didn't do these things.

And you know, so let's be proactive. We tend to want to react and then we don't know how to react, because in the moment we have some guilt and shame over that. I call those five-minute emotions. You feel them for five minutes. You let them have their impact on you, but then we got to move on from it. But we have to do it effectively. And so if we know we're meeting weekly or monthly in our team meetings, let's take 10 minutes and we have courageous conversations training. How do we do it? We don't like to do it. We don't want to talk about it. We don't want to think about those things. But these things happen. In that courageous conversation, it's a time that I say, "Well, here's the thing that I'm not proud of that I did this week, this month, with this interaction. I could have done this better." But again, that's me admitting my mistake, my flaw.

But when I as a leader or whoever can do that, think about what that does to the person looking up to me, I've created a space to say, this is psychologically, this is a psychologically safe place for you to admit your mistakes, for you to end. You're not going to be judged on this. Courage is one of the six Cs of inclusive leadership that the Lloyd talks about. And then there's commitment. So if we're doing this daily in practice, then I know we're talking about intention versus impact. It's not your intention. I do not believe that you walked in today with the intent to do X, Y, Z, but this is the way that it happened. This is the impact. And we are committed to not allowing it. We all make mistakes.

And again, we're sharing our mistakes in this moment. And can we have this time to say this is us admitting that we're not perfect. You know, as great and wonderful as I like the thing I am, I'm not perfect. I make mistakes all the time, and I am courageously admitting today. And so how do we get better?

Becca: When I listen to all of these suggestions, what I really hear is it's about, you know, really caring for individuals and having a caring response, and then also respecting people. I think there's kind of two key things there right? We're respecting others, but we're also realizing we're that we're not perfect and we have to be caring in the way that we respond to each other and building relationships, but also considering that we have power over people. And if we're working with patients and students that we also have to be really conscious of how we role model what we're doing.

And that's part of also preparing students and other professionals. And I think we've talked a bit about this, but seeing that this is common and it's happening across our profession, the final thing I want to ask you all is to consider, are there other things that are calls to action or things that we can do to prepare the next generation, the current generation? What do you think are those tangible steps that you would recommend that come up to inspire other people who are listening that might be kind of tangible next steps?

Julian: I think one of the biggest things, especially for the next generation, and even though that we have right now is that we have to go back and place emphasis on, and I hate to use this term, but I will, in the soft skills, right? These are the hardest things to master. It's not so much as, "Oh, I see this shoulder diagnosis and I do this evaluation." It's, "I have to be intentional about what I'm doing in this moment for this person." And I have to see them as a whole person, and I have to know that they bring in all these things. And then I have to know where I stand, and I have to know my own limitation. I have to know what it is about me.

And we don't emphasize enough in, I think physical therapy education. The course is usually a one-time thing where you talk about ethics, right, and how many people are probably secretly studying for anatomy. But it's these things that cost you the most because you don't know how to form these relationships, and you don't know it. So it needs to be not just, we're talking about ethics. We're role models. This is brought into our cases. And again, we're in practice. We're talking about, well, what are the ethical implications? You know, what was the moral dilemma here? What, you know, all these things from that standpoint, how are we addressing it and making it active to where learners are saying, you know what, this is a consideration that I always have to have. It's let's take it from the background and put it at the forefront of everything.

Becca: Thanks, Julian; that's great. Karla, what are your thoughts?

Karla: Yeah, it's funny. So, Julian, I call those human skills, after Simon Sinek actually uses that term that I've adapted in my classes. But I would also say I'm thinking a really important way to couch this, and I do through my teaching and then my work with my colleagues, is talking through an impact lens. So whenever there is a crucial or courageous conversation or an attention moment or something that happens, right, is to start in your head, your first thought is, what was the impact? To who was the impact to and what was that impact? So that takes that, it takes that emotion away, your initial, it drives that emotion down, of that emotional response, and it brings out your emotional intelligence, in handling that response.

And if you look at things through that impact lens —  and I teach the social determinants of health and the structural determinants of health and the political determinants of health through that — so you can have these discussions where people say those are political discussions, and these are the same things. These uncomfortable conversations when somebody's microgressed and you have to speak up. These are the same kind of conversations that happen. And if you approach it through, "Oh my gosh, who was impacted and what was the impact?" then you could immediately go to what are we going to do about it. Instead of, "Oh my gosh, I didn't mean it." And then you get you get caught up in the weeds that are not the important part here that we need to address. And so I think using that impact lens and that impact mantra in your head is a really powerful piece.

Becca: Thank you, Karla. Keshrie, do you have any final thoughts?

Keshrie: I was thinking about the active bystander piece and the allyship that Karla was talking about and thinking about it as being a verb and being this, there's lots of bystanders, right? But how are you an active bystander? If you heard something that made you feel uncomfortable, and you were courageous and you stepped in without centering yourself, so you, whatever you observed, you asked the person if they need your help.

And these types of conversations, they don't have to be scary. Sometimes it's just giving people the opportunity to walk back something that they said, "I'm sorry, I didn't hear you. Can you repeat that?" And once the person has heard it out loud, they may not say it again. Or just simply, "Some people may find those words offensive. We won't use them here in the clinic again." And then that's it. We've set a boundary; we've changed it. But people can only change — clinicians, patients, students — If it's brought to their awareness, right? But not talking about these things hasn't helped. We're in a very divisive state at the moment, right? So we can make things better by bringing some of these things out in the open.

Becca: Thanks, Keshrie. Debra, any final thoughts?

Debra: I agree with what everybody has said, and it's been so enlightening, but the bigger picture is if ethics is about relationships and it's all relational, then it's all about ethics and how we choose to act towards others. And so these conversations do need to happen, and there are skills like Karla talked about that can be employed and learned to address microaggressions, but also to address our own biases so that we don't say things that we don't mean. But if we look at it from a lens of, it's all relational and we do have professional responsibilities to build relationships, I think just getting that stuck in people's heads and modeling that is the first step forward. Because that's a baseline assumption.

Becca: I just want to thank you all for your thoughts. I feel this is very helpful, and I'm hoping that the audience that's listening is really feeling more informed. And I think really some inspirational ideas and some things I'm going to take with me from amazing, amazing thoughts. And I just want to remind you all too that there is the APTA Magazine column that is also related to the same topic. So we hope that you'll check those out. And we thank you for your time listening today.

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