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Building equality in physical therapy for marginalized communities is a challenging and complicated problem in our country, which will require cooperation across the political spectrum to solve. Whether the people in these communities are identified by their race, their sexual orientation, or their religion, each one deserves a safe space for receiving healthcare.
To start, there are systemic issues that need to be acknowledged and addressed. Did you know that as of April 2023, there were already 452 anti-LGBTQ laws in state legislatures around the country? This is more than all of the previous 5 years combined, which equates to about a 15 fold increase.
It is clearly obvious at this point, that there are many people who feel unsafe in a variety of places around our country. A physical therapy clinic or hospital should not be one of those spaces.
With that in mind, it’s difficult not to see how critical it is that we begin building equality in physical therapy. We need to make a safe space for each individual in our clinic no matter what their age, gender, sexual orientation, race, or religion.
It’s difficult to know the true health status of a community when there is an absence of data. It’s the reason why so many women struggled with heart disease disproportionally to men. The scientific community assumed that researching men gave enough information to appropriately treat women’s heart disease. They were wrong.
This is equally true for the people in marginalized communities. We need to perform more studies to learn about the health of these communities in order to build equality in physical therapy. But this isn’t as easy as just doing studies. We need grants, financial support, and the ability to ensure safety and protection for the individuals of these communities who are often fearful for their lives because of upcoming legislation, fear or losing their jobs, or even losing their housing.
Why is this so important for Integrative and Lifestyle Medicine? Because we know that certain social determinants can contribute to significant negative health outcomes. We also know that stress, especially chronic stress, leads to a host of health conditions that will dramatically reduce a person’s quality of life.
When an entire community is underrepresented, they are at greater susceptibility to inequality in healthcare. They are more likely to struggle with chronic health conditions, trauma, and overall inadequate care.
When we can treat patients using psychologically-informed and trauma-informed methods, we are able to create a safe space for the people who previously felt threatened or fearful with their healthcare providers. Integrative & Lifestyle Medicine means more than just getting a good night’s sleep, eating well, and exercising. It also means treating the individual who is sitting across from you with the full respect that each human deserves, regardless of their circumstances.
Dr. Ginger Garner sat down to discuss this topic in greater detail with two leaders in the field of building equality in physical therapy for marginalized communities: Dr. Melissa Hoffman PT, MSPT, PhD and Dr. Karla Bell PT, DPT, PhD(c).
For those of you that prefer video, watch this discussion around the topic of building equality in physical therapy and healthcare for marginalized communities.
You can check out their chapter, “Health Disparities” in the book, Integrative and Lifestyle Medicine in Physical Therapy. Additional contributing authors to this chapter were: Chris W. Condran PT, DPT, MBA, Alexis Ortiz PT, PhD, and Rosa Elena Torres-Panchame PT, DPT.
Ready to take on the challenges of building equality in healthcare without getting burned out? Join our FB Group to help eliminate burnout in PT/OT entrepreneurs today!
00:00 Dr. Ginger Garner Hi everyone and welcome back. This is Ginger Garner and I am here with Dr. Melissa Hoffman and Dr. Karla Bell. And I am overjoyed to have them with me today. We’re going to have, you’re in for an amazing discussion. But before we do that, I want to pause and give you a little bit of information about them and their bio. I’m going to start, Mel, I’m going to start with you first. Just because you’re top of the list here on my script.
Dr. Hoffman has strived to embody elements specific to a Jesuit education, leadership, value-centered education, social justice, service, research and scholarship into her practice. In using these elements as a guide, she’s been able to model a positive impact on students that inspires them to become conscientious clinicians as well as to prepare them to live in a mature and responsible manner. In addition, by integrating questions of meaning, ethics and values into her teaching and work, Dr. Hoffman has been able to implement more appropriate and challenging learning experiences to promote further social and cultural growth of students and patients alike.
Through multiple service opportunities, she’s extended her knowledge and skills to underserved communities of the world and has come to understand the importance of social justice and sustainability. Finally, by furthering her education in the area of research and statistics, that makes that give me a little chills, you know, statistics. I survived statistics, my doctorate, but I didn’t say I loved them. So, you know, hats, hats off and applause for that. She’s able to postulate and investigate a multitude of research questions as a research educator. Dr. Hoffman is able to provide opportunities for faculty, staff and students to advance their knowledge base in research, thus allowing for further dissemination of pertinent research outcomes across physical therapy and abroad.
And Dr. Karla Bell is an associate professor of physical therapy in the Jefferson College of Rehabilitation Sciences in Philadelphia. She also has a secondary appointment because she’s not busy enough in the Jefferson College of Nursing for education and training in diversity, equity, inclusion and sexual and gender diverse content. In Karla’s 25 year career, their clinical career has included various settings from acute rehab to outpatient. That’s a big span. And they had dual board certifications, also a big deal in orthopedics and geriatrics. And with an academic career, that spans 18 years. Karla is also a candidate for a Ph.D. in population health sciences.
Oh, my gosh. If there was only enough time to get I would love to get a Ph.D. in that. Amazing. With a focus on behavior change. Her dissertation work is on health care provider behavior change and mitigating health care disparities for SGD populations. Carla’s expertise in curriculum inclusion of SGD health and faculty and staff development, education and training in sexual and gender diverse population, cultural humility, inclusive practices and determinants of health. Current research consists of national collaborative studies and LGBTQ plus barriers in PT and validation of belongingness tool in PT. They’re also on a national interdisciplinary educational research study on sexual and gender gender minority education and training for faculty, staff, admin and clinicians. Karla has two publications and several and current submission to back book chapters and over 50 presentations at local, national and international venues.
All right. Thank you guys for joining me today. I just can’t tell you how thrilled I am for you to be here. And so I just want to open up with the question of how did, tell me a little bit about yourself. How in the world did you choose PT with all the talent and opportunity that you have to give to the world? Why PT?
04:26 Dr. Karla Bell: Mel, you want to go first?
04:28 Dr. Melissa Hoffman: Sure. I’ll go first. Hi, everybody. I’m Mel Hoffman. So glad to be here with everybody today. I’m from Colorado, originally from New York, born and raised on Long Island. But now I reside in Colorado and I am an associate professor at Regis University in Denver. Currently, I continue to work at the University of Colorado Health. I’m a senior physical therapist there. I’ve been in the profession for almost 25 years now. So it’s been a long time working like Karla. Very busy on the research front with sexual and gender minority research specific to the LGBTQ community.
We are looking across clinicians and faculty and students and patients on their perceptions of the climate of cultural competence within the physical therapy field. Also working with the transgender community. Just started a study a couple of months ago in collaboration with the University of Colorado Health, looking at the implementation of pelvic health for individuals that are status post vaginoplasty procedures. So lots of good work. We’re developing and validating a tool for cultural competence that is specific to sexual and gender minority communities in the physical therapy profession. So we’re both very, very busy on the forefront of very novel and groundbreaking research. So we’re really excited to be here to be able to talk with Ginger today.
A little bit about how I got into physical therapy. So, wow, Ginger, that is a hard question because that goes back a long time to the early days. But in those days, they didn’t even have doctor physical therapy programs yet. So at the time that I was, I won’t speak for Karla, but she’s a little older than me. But going back, the programs that we had were BS/MS, so bachelor master in science of physical therapy. And so I graduated in 2000 with my master’s in physical therapy and went straight out into the world of practicing. But I have to say, getting into I think early on, probably in high school, is when I started to gravitate towards physical therapy.
And naturally, a lot of us physical therapists will say the same thing, right? Because we sustained some sort of injury that led us to go to physical therapy. And then that kind of led us into the field to want to help people. I will say that early on going into physical therapy and the idea of physical therapy, I didn’t really know where I wanted to concentrate my practice. I think going through the five years of my master’s program really helped to guide me and really focus me on the area that I decided to go, which was more of the hospital based acute care, neuro trauma kind of direction. And so much of my experience in the last 25 years has been really higher level, very dynamic and intense intensive care and trauma neuro intensive care units. So it’s been a really fun ride to get where I am today.
And I still practice at the University of Colorado Health. It’s very diverse. The areas that I get to work in in the hospital, I can pretty much go to any unit. And there’s a number of units from the pulmonary unit to the orthopedic unit, the geriatric unit, to the bone marrow transplant unit, to all of the ICU units.
So it’s very diverse and it’s a great opportunity to continue to learn and really hone my skills as I am now teaching in academia and want to and try to stay relevant. So, yeah, that’s kind of the underpinnings of where my physical therapy experience came from.
08:44 Dr. Ginger Garner: Cool. I want to point out two things from that. One, I’m so glad that you’re doing the research on pelvic health. That’s going to be critical. And then two, if you’re listening to this and you’re considering PT as a career, just from what Mel said alone, know that you’ll never be bored. There’s always something exciting and a different path that you can take. There’s so many different ways to focus on PT. And Karla, before you answer that part of the question, I also forgot to mention that Karla and Melissa and several other authors (yeah) that were co-authors on in Chapter 20 in the book, which was on health disparities.
And one more thing I want to point out, because you mentioned the acute care and neuro and everything. Now, when we all were in PT school around the same time, I graduated from Chapel Hill in 98. So this is my 25th year. I don’t know what is that a silver or diamond or something? What is that? I don’t know. Maybe I should celebrate it come August, because that’s the official 25th birthday for me. But we weren’t looking at this stuff 25 years ago. We weren’t even talking about the title of the book, no lifestyle medicine. I was doing yoga at the time, but I was homeless and kind of displaced and yoga wasn’t taken very seriously. So I think it’s important to mention that, you know, because we all grew up being trained in PT in these master’s level programs without any mention of this.
So I think it’s really relevant, you know, our origin stories of how we came into PT, because we’ve live in a different world now (thankfully) with what PT has evolved into.
10:42 Dr. Karla Bell: Absolutely. So hi, everybody. Karla Bell, my pronouns are she and they. And you heard my bio in the beginning. So jumping to kind of my path to physical therapy. I mean, again, we all mentioned that we all graduated pretty similar times in late 90s, mid to late 90s. And I would say, you know, in choosing the career itself, it had already been in my head before I went to college. And I think if I can attribute this to my father, actually, I can kind of attribute this to my father. He was very instrumental in helping me explore careers to go into.
And physical therapy was at the top of both of our lists and medical school. Right, so certainly going through undergrad, I had made the decision at that point in time being a biology and chemistry major, I was going to go the medical school track. But really kind of felt I was missing something when making that decision. And then my world kind of got rocked. My father died suddenly a month before I graduated college. And it made me reevaluate my decision making. And I was like, well, if he was in his mid fifties and died, like, what do I really want to do with my life?
And it came back to my passion, physical therapy. And certainly it was a culmination between what I thought I could have in terms of impact with the people around me in society and being able to spend time with them. Right. And that was crucial. And I kind of already knew the medical school track and being a physician even at that time was not spending a lot of time with patients.
And for me, that was really front and center in terms of being able to get to know my patient. And we talk about lifestyle medicine and integrative medicine. You know, I just I feel like that is the key to helping with the health outcomes, ultimately. Right? And we have a unique experience in our profession that we get to spend more time with our patients. And that is a tremendous blessing. And I do believe that we’re going that way. And we need to, I’m getting my PhD in population health. I can talk for days about what’s wrong with our health care system and delivery system in this country. And we definitely need reform. And if our profession could embrace this collaborative practice, team centered approach and integrative medicine approach to holistic patient centered care.
I think it will go a long way to helping those outcomes and culminating into where I am now in my profession. Right? My social justice roots always existed as both a sexual and gender minority in that development through my career. I was always involved in social justice movements and they were parallel processes. Right? My profession and my social justice roots. And it culminated in some discriminatory experiences I had in our profession.
And I was like, OK, like this, this is actually should be these should be meshed in my service. They should be meshed in my value based leadership. Right. And so my social justice roots started meshing with what I was doing in my career.
14:31 Dr. Ginger Garner: Yeah, you know, when we can bring in those in our lived experiences, our passion, what makes us want to get out of bed in the morning, what we love with what we do, I don’t think there’s any better way to be living. I mean, that is kind of the culmination of what we’re supposed to do with our lives is to plug in in that way. So to hear your guys’ stories, you know, really living should inspire everybody and also motivate people to plug into what matters in your life.
I thought I was going to go to law school. So I think that’s where the social justice, health care justice piece I’m very passionate about because I wanted to argue for those things that are right. But I went to one law school and symposium at UNC and it was so boring. I thought I don’t know how I’m going to I don’t I can’t sit all day like and, you know, it’s an intriguing profession.
But, you know, physical therapy became the thing for me as well. So the fact that we get to combine these things and also remind students and people considering PT or medicine in general and health care in general is that everyone can be an advocate to stand for what is right. And and and what I think all three of us believe is right is that everyone should have access to health care that’s affordable and whatever that way that they need it.
So based on that, I hear favorite things that a physical therapy, I think we’d agree, is we get more time with patients. We get to have a relationship with them. We get to create safety with them. And I think that if I had to say one thing that’s most important about what we do is that if we can’t create a sense of safety, we’ve lost our ability to leave any impact or imprint on our patients at all. I know that’s one of my favorite things about about being a PT is having that time with them. It is an incredible privilege, but it also brings up the point of. I think for us and this question is for you guys, using Integrative and Lifestyle Medicine in the LGBT+ community, how did that come together for you guys? How did you go – I can’t I practice without this?
16:54 Dr. Karla Bell: Yeah, I mean, Mel, do you want to go first again?
16:48 Dr. Melissa Hoffman: We can go back and forth? It’s fine. Yeah, you can go.
17:02 Dr. Karla Bell: Yeah, great question. And and and I, you know, and reflecting on what we were going to be talking about today, you know, thinking through that and where it kind of started intersecting with my practice and my kind of values and my view. On what is important in our profession, right? I’ve always held the view that physical therapy, just like all health professions, needs to be holistic in our views and treatment of patients, right? And, of course, I talked about the intersections of my lived experience as a member of the LGBTQ+ communities and these really influenced my passion and direction in Integrative and Lifestyle Medicine and helping these communities to be seen through an equity lens.
And for me, really, that has culminated in everything that I do now. Right. And I’m certainly on more of the educational side versus clinical practice now. But looking back, the natural pieces of Integrative and Lifestyle Medicine started showing more and more in my approach with patient care because I realized we were not providing what we say patient centered care is. Our health outcomes are not reflecting that. And certainly patient experiences oftentimes are not reflecting that depending on settings and you know, busy PT clinics, yada yada.
And I really thought, like, if I just concentrate on me and what I’m doing right and hopefully I can help role model this for students and other practitioners. Really took this view that we need to know much more from our patients, than how we were taught how to do those quick subjective screenings right and get right to the you know what body part right and. And, you know, I realized patients are wanting more. Patients are wanting to feel like we care about them as a person and not just somebody who’s coming to us with a body part or a limitation. And so that’s kind of my, you know trajectory into that approach.
19:09 Dr. Ginger Garner: Yeah gosh that resonates so strongly with me. Because you know when we all first started out in clinical practice, you know the intake forms were what’s the body part? What hurts? Okay, where is it? All right, you’re done. And my intake forms today I warn people like, “I’m sorry in advance, but the intake form is really long it’s going to ask you even what music you like because I care, you know if you have religious preferences I care,” you know. So that just that hits me, that hits home for me.
19:43 Dr. Karla Bell: Well, and Ginger just to tag on to that quickly it it speaks to us setting up cultural safety if we don’t know things about the person in front of us, we cannot set up cultural safety.
19:57 Dr. Ginger Garner: Yeah, absolutely. My head’s like bobbing off, yes.
20:03 Dr. Melissa Hoffman: Well, and also you know I think what a lot of folks don’t realize and especially you know some of the some of the elder folk, right, that didn’t really have this information integrated into their curriculum. So really, you know going out into the world they didn’t really have that awareness, so you know there’s some unfairness. Right?
To bias people because of that, because we know like it just wasn’t in the education, but it’s more like what are you doing now and what is your acknowledgement now, knowing that there are so many different intersections that are intertwining. into your practice. And so, it’s almost like a responsibility, I feel, of any provider to acknowledge who people are and what intersections.
Like you can have somebody from the LGBT community, but they could be from so many other intersections as well as that, right? Right, based on the color of their skin, based off the religion that they practice, based on the fact that maybe they have a disability. Right? So there’s all these challenging intersections that we as providers, to provide holistic care, need to be aware of you know.
And you look at you know this lifestyle medicine book to start, and if you look at the table of contents and you look at all of the areas that are covered in just this book. I mean I’m looking right now: diet and nutrition sleep and relaxation, tobacco cessation, pain management, mental health, and wellness. Right all of that means something and I have to agree with Karla on this, we don’t have enough data right?
Our world, our profession has been very, how do I say this, choosy about who they’re choosing to study and what data they’re choosing to collect right and so there’s so many other communities that we haven’t even tapped the surface and the LGBTQ community is one particular community which we don’t have any data, I mean we’re not even collecting data. You know about the people that we’re sending out to care for, you know individuals from different communities, so.
You know, in that we could go down the rabbit hole right and into educational practices and curriculum and what we’re providing people and how we’re screening people. Before we send entry level therapists out like what is our demographic of our programs, right? So overall, I think, for more vulnerable and marginalized communities, we don’t have enough data, and so, in order for us to really be able to implement change. On a larger level, we really need to have folks that are willing to go out there and collect that data and and then to and also to advocate for legislation that is going to really require that that data be collected.
20:01 Dr. Ginger Garner: Yeah, let’s dig into that a little bit more actually because in the book chapter you do go into types of health disparities. So, if maybe one of you could speak to the types of health disparities, so that we can, for listeners who may not be a clinician maybe they’re just interested in this topic. What are some of the types of health disparities that we are faced with in health care and physical therapy and then the second part of that question would be maybe whoever wants to take the question is the root causes of those and the drivers of those health disparities and see where that takes us.
23:32 Dr. Karla Bell: Mel, I think you’re up first.
23:37 Dr. Melissa Hoffman: You know we’ve done quite a bit of research on on health disparity, and you know I can go on and on and on and on on this call because there’s so many. But you know there are disparities around of course health right so mental health. there’s disparities, you know, for us in our communities, what we have researched we’re looking a lot of the disparities there’s there’s an array of disparity across. The different members of our communities right, so we think about, for example, lesbians you know there’s disparity around lesbian health right? And so, maybe they’re smoking cigarettes more so maybe there’s a higher incidence of cancer. For lesbian communities, for individuals that are gay, you know the disparity around gay men has been HIV.
So there’s a number of different disparities, but I think what it all comes down to at the end of the day is access and you know Ginger I know you talked a little bit about that earlier, but a lot of these disparities, they precipitate due to a lack of access or an unwillingness, in most cases, to even access healthcare, right? And so bad things happen when you don’t take care of your body right and so it’s like the sliding scale downwards. It’s just a slope that you can’t recover from. You know, it’s a national problem and it’s this is not something that’s just happening within the communities that we study. This happens across the board with all different marginalized communities, the things that I hear that individuals that have disabilities go through is astounding! And the disparity that follows them because again they don’t have resources to be able to access healthcare.
Like I said, we could talk about all different types of health disparities. If you’re interested, get this book and read the chapter, but it’ll go into more depth and detail that we don’t have time to discuss entirely today.
I’ll kind of start the conversation as far where I think this comes from, but I like to think about the socio ecological model of health and I know Karla is very familiar with this as well, but I think that’s where you know when I think about the socio ecological model of health i’m thinking about where is the breakdown. So there’s a number of different levels where we break down. So we break down at the interpersonal level, you know so that’s like within ourselves right what do we believe. You know it’s just our misconceptions or conceptions about anything right in life.
The intrapersonal level is moving out more to like your coworkers, your friends, your family. Then we move into the organizational level, so what is the institution’s capacity to address these issues, and then we move to the Community level and then finally. To the societal level right and so there we’re looking at things like policy and legislation that advocate for different communities. So I think that, you gotta go back to the very beginning. To where it starts.
If it’s not happening at the very beginning at the interpersonal level, then you’re like okay well, what does it look like moving up each level right and those are the I think those are some of the challenges as we move up that level and you really have to be able to move up to the level that you’re at. Right? As we move up that level, you really have to address each level to really have the education and the awareness to be able to address these issues. So Karla i’ll let you follow with that and i’m sure she’ll dive in a little deeper at that level.
27:47 Dr. Karla Bell: Sure, thank you, Ginger I didn’t know if you had any follow ups from Mel or you want me to just dive in.
27:53 Dr. Ginger Garner: Yeah, Dive in. I’ve got things. What came to mind first is thinking about Dr Riane Eisler who’s a social scientist and a Holocaust survivor came to the US through Cuba and was expecting to see a very different functioning country than she did. Then she went on to dedicate the rest of her life, she is still living, to explore social science as an attorney. And came up with a theory of caring economics and talking about the lack of the value of caregiving in our country and how, if you look at other societies Nordic countries, for example. And their example of the equity that they have there, they are a much actually wealthier country as a result in all planes, whether it is material possessions or psychosocial wealth and health, then we are because of that lack of value of caregiving.
28:53 Dr. Karla Bell: Yeah, great thank you for that point. And just to elaborate on some of the points that Mel had already spoken to you know i’m going to go right to kind of my perspective of root causes right upstream effects that that culminate in these downstream disparities right.
Certainly, we as a profession,in all health professions, but we’re talking about our profession right. really, really needs a culture shift in its understanding of informed practitioner. About what’s going on in the world around us and the impacts on the patients walking in our doors. What I mean by that is, yeah we start dabbling in social determinants of health and educating our students about that and some practitioners are you know, have been practicing for a while or learning a little bit about that, and now some people are even collecting some data regarding social determinants of health of patients.
But really and truly we need to take a bigger and larger view on how we’re doing that. So this goes back to lifestyle medicine and integrative medicine to the approach, because we can’t set up and provide the the tenants of those lifestyle medicine and integrative medicine, so you know talking about prevention talking about healthy lifestyle choices, all of that stuff until we actually know what informed their current status.
So we need to understand the social determinants of health 80% of that person’s condition, right? We also need to understand the structural determinants of health and the political determinants of health and those are different.
So you know people often say isn’t that all included in social determinants health? No. It’s that the political determinants of health actually is a newly coined term by Daniel Dawes. Political Determinants of Health book. 2020, excellent book. Speaks to the fact that those determinants shape the social conditions that give us the social determinants of health. So they’re actually above sort of this contributor to the social conditions of social determinants of health, yeah. And if we don’t get on board with the social determinants of health. And if we don’t get on board with knowing that and understanding NOT from a bipartisan politicized viewpoint.
We need to start talking about political determinants of health at the impact level. I don’t want to talk party, I don’t want to talk anything I want to talk about: this was introduced, this is getting passed, who does it affect downstream? That’s what I care about. And what are those impacts? And what is that person walking in the door? What possibly the root causes of that is all the way back up to the political determinants of health. Right? We’re going back to examples like redlining and how that set up our country for these populations, people of color to have less access to nutritional foods, where they had to live, you know all kinds of things right.
And so, again we’re talking about in this day and age for the populations that we wrote about in this book, we are looking at 452 anti-LGBTQ+ laws on the books right now, and it is only April, that is more than the last five years combined. And so. And so. You know what does that mean? Well i’m going to be honest, you know if somebody doesn’t think that has anything to do with our profession. The least I can tell you is guess what it actually changes the way you can practice in some states now, so it does have to do with our profession, even if you don’t want to talk about the patient impact and what does to that patient. You can and cannot do some things, depending on the state you live in right now. So we need to get on board with understanding these root causes, because they are having an incredible impact and I think we’re coming to the perfect storm in our country now where we all in healthcare are going to start recognizing that we are focusing on the wrong things.
32:54 Dr. Ginger Garner: Yeah I think that if we could say that’s kind of a reckoning, because there are, if I just look as staying plugged in as our liaison for at the federal level and at the state level for APTA through Private Practice and through Academy of Pelvic Health and through APTA in North Carolina. Bills have come across my desk just in the last few weeks, I am shocked that unless you’re following what’s happening in the chambers at the North Carolina General Assembly no one knows about them yet. They’re not public but it’s shocking actually some of the things that are coming across the desk that will impact our ability to practice and as women to get basic healthcare and have you know rights and access to healthcare and control over our own bodies. When I start talking about things like this, I start talking faster. fired up about having access to care, because the minute people say it doesn’t impact me I’m like we’ll wait, because it will.
And at some point, they will come for your healthcare access rights as well, and they already have in North Carolina. If we had another hour to talk about it, we could definitely dig into that with the lack of expansion of medicaid which has cost us billions and really had a massive impact when over 500,000 North Carolinians have not had access to healthcare since 2010.
34:17 Dr. Melissa Hoffman: Well, and a lot of that Ginger too is you know there’s this real element of fear now right, and so you know different communities are living and breathing a very hostile climate. And so there’s real fear involved and what does that do to access right? So you know there’s all these other health disparities that have come from the discrimination and the micro-aggressions that individuals experience from these communities every day, but now, on top of it, we have policy that’s inflicting fear and harm on people.
So, when we talk about collecting data around these individuals were even less likely to get data because people just aren’t going to share right. They don’t even want to access healthcare. Do you think that they’re going to be open about sharing the most private pieces of who they are? Because there’s fear around, ‘well what happens to me if I do that?’ And I can say even just in our focus groups with patients that we did there was a real element of fear. We really had to inform these individuals that it was a truly safe environment and that this information was not going to be leaked. But it was so bad, that some individuals came on and they wanted to talk to us and they did talk to us, but they didn’t have their cameras on. Right, because there was fear that even somebody that was on the focus group with them would know who they were and then go and tell somebody. Sso you know that fear is a real, living experience every day. Not only for sexual and gender minority communities, but any marginalized community.
36:04 Dr. Ginger Garner Absolutely to hear that personal story should make everyone pause that someone is so afraid for their own safety just to have to talk about their healthcare and their experience their lived experience, it should not is not where we should be in 2023, at all.
36:28 Dr. Melissa Hoffman Or even to talk about who they are. They can’t even answer half the questions on the intake sheets because they don’t know who’s going to see that. Where is it going to go? Am I going to have a job? You know, a day from now, am I going to be able to reside in the place where i’m residing? Am I going to get kicked out? Am I going to be homeless? Is my family going to you know not speak to me anymore?
36:55 Karla Bell: Because all of those statistics are really high right now, right? And what we’re talking about as a categorization we went from health disparities now we’re talking about the effects of discrimination in healthcare and those are health care disparities. We as providers are directly responsible for those disparities.
37:13 Dr. Melissa Hoffman: That’s right.
37:14 Dr. Ginger Garner: And when we zoom out and we look at the overall picture and you see this institutional trauma and institutional if you can say violence inside that trauma. Healthcare-generated trauma and then, as a pelvic PT I have people come into me with having experienced that trauma inside the institution, where does that put me? What kind of and not just speaking to me, but anyone who provides this care, what does that where does that put me as someone who is trying to help someone who has actually experienced trauma inside the hands of the healthcare system? How do we handle that?
37:43 Dr. Karla Bell: On a daily basis, in a number of ways, right?
37:59 Dr. Melissa Hoffman: And then, trying to convince them to come back, right? What does that look like? Because their experiences could have been so poor and so volatile leading up to them coming to you that there’s no trust. Like you talked about earlier. There’s no trust there. They don’t trust the healthcare system.
38:18 Dr. Ginger Garner: Right and I often lead with that because again on those lengthy intake forms that I have. You know I do get a little bit of that information, you know from them, most of that is gleaned when I’m actually talking to them. But to say you to validate their experience and to say you have a total right to question everything that I say to you. And to be skeptical and to feel the way you’re feeling because what happened shouldn’t have happened to you or anyone else. And I think that you know as new PTs if you’re a new PT are you thinking about healthcare in general or getting into healthcare that may be one of the most important things to consider is how you’ll establish trust and a sense of safety with your patients or your clients.
39:05 Dr. Melissa Hoffman: One of the other themes that has come up in our research also is leadership. So what kind of leadership? This is a theme that just keeps popping up and it means something, right? I go back to that socio ecological model, because as we move up, you know who you are as a person, how you interact with others, that is in your awareness around all of that is going to impact everybody at the organizational or institutional level. And you as a leader, you’re setting that example for all the constituents underneath you right, so if there is a lack of awareness at the leadership level, and there is in many places. It’s actually accepted in many places, those places that are more discriminatory in nature. Then that’s pushing progress back, instead of forward. Then we’re not providing opportunities we’re not providing opportunities for people at the organizational level to even learn, even if they want to learn they don’t have the opportunities to do so.
40:14 Dr. Ginger Garner: Yeah and that’s a huge challenge for us in our profession in physical therapy. It’s a huge challenge for healthcare in general. So one of the one of the questions I have is, I mean we could ask this in two different ways. One is – what are the biggest challenges we see physical therapists facing today and what can we do about it? I mean that’s one important question because we’ve raised a whole list of issues with respect to health disparities and they all deserve attention. But what do you guys see as the biggest challenges facing PTs today and how do we address it?
40:56 Dr. Karla Bell: No, that’s a great question and you know I can’t pick just one. Certainly I do think it’s multifactorial and again I’m going to say culminating in somewhat of a perfect storm in this. 2023 status, we are in this country. So we’re talking about things like debt to benefit ratio to becoming a PT. People weigh whether ‘is it even worth it for me to go into that kind of a debt to get paid what i’m going to get paid coming out’.
Lack of diversity in our profession and the ability to continue to connect. And set up cultural safety for the communities we serve right. Of course reimbursement and payment rates, we have to talk about that and truly the healthcare system, the US healthcare delivery system in general. It doesn’t allow us a full place at the table as primary access providers, right. Which, in a way, I believe has contributed to some of our tunnel vision in our profession and leadership and the directions we go in our profession.
You know, team care and collaborative practice is really where we need to go to be holistic and effective in our care. And the population health research is really showing this. If we get team care right, the health outcomes are way up. We need to shift to the primary focus on healthy lifestyle choices as part of our plans of care. I’m going to be honest with you, it’s rare that I see patients getting sessions that consist of the tenets of both lifestyle medicine and integrative medicine – they don’t. And so we really need that. Those are some of our biggest challenges, I think, from my perspective.
42:53 Dr. Ginger Garner: Yeah, that last point you made is so true, this was several years ago, and I do not think that it has changed, and I won’t mention the very large hospital system that that one of my patients received care at but they had an integrative medicine program. This person was going for oncology care and they advertised a big integrative medicine program. And when this person went to receive care, they were told that it didn’t matter what they eat when they’re going through their chemo. Just eat whatever you want, it doesn’t matter. So the basic tenets of you know sleep, nutrition, physical activity, mindfulness. All the things that the literature overwhelmingly supports and that we have the evidence for weren’t actually being practiced. It was a lot of lip service, I gotta say yeah so that was very disappointing.
43:50 Dr. Melissa Hoffman: I want to add just to this conversation is I think one of the challenges you know in looking at the research that we’re doing right now. I can be specific to our community. There’s not a ton of research in this area, I mean before we started on this journey of doing research around sexual and gender minority communities and then all the intersections that overlay that. You know you go into the literature and there’s maybe like five articles in the last 10 years that have been published. So that’s a problem, right that’s a challenge. Like what’s going on within our physical therapy profession and community that this isn’t being discussed and what are the barriers to why this isn’t being discussed. And there is an absolute necessity that more individuals get involved in research.
And I don’t know, maybe like some people don’t know how to get involved in research, maybe some people are you know around these types of sensitive topics, maybe they’re afraid to get involved in this type of research. But research brings more research and you know we have to have bravery amongst our profession to go out there and do this work. They can’t sit on the shoulders of just a few, there needs to be many that like Karla said that get involved in this process. And so you know there’ll be a slew of articles that come out from our work and we’re hoping that it facilitates more individuals getting involved in this movement.
And that we see more we see more data. There’s no hard data right now, like all the research that we’re doing is exploratory. It’s all exploratory what we’re doing. We’re doing qualitative focus groups. We’re doing qualitative interviews. We’re doing exploratory and descriptive surveys because we’re just trying to get kind of the foundation and the climate of where we are now, currently. Where we were, where we are now, and then we’re deriving solutions and strategies that we can put forth for the future. So we need more of that right, but there’s just not enough of that. Just a few people doing this research is not enough.
46:22 Dr. Karla Bell: And I just to add to that now too, as you were talking I was also thinking about the other challenge I didn’t mention. Is leadership in our profession. I’m going to go back to, we are talking about health disparities, that’s our chapter. We have our public policy priorities for our profession that have been published. Health equity is in there. However, I’m going to ask the question because I really honestly haven’t seen it, what are we advocating for? You want to talk about health equity? We have to be advocating on the political side. Now, we’re getting obliterated in the political structures, and we have an organization that is not giving any leadership behind talking about the impacts of what that legislation is doing to the communities that we serve. That’s a mistake and we have to have a culture shift around that. You’re going to make some people unhappy, but we have to be on the right side
47:19 Dr. Melissa Hoffman: And there’s actually people out there, you go to any of the Facebook or the or the Twitter streams, you know in our profession, and there are enough folks that are out there that don’t even think that policy should be in our profession, which is absurd. Right it’s absolutely absurd, but so what kind of education, I mean this is a lack of education.
There are providers, like us, out there that don’t realize that policy plays a role in change. Right and so it seems so simple right, but there are folks out there that don’t know what they don’t know. Some of them don’t know what they don’t know. Some of them just don’t want to know, right? Some of them are blatantly just like I’m never going to know. But it’s so critical to implementing any type of change, and if we have people that are out there that are saying I don’t I don’t want to learn about that, that is a huge challenge.
48:26 Dr. Ginger Garner: Yeah, I think what people don’t understand and you’re right why they don’t understand? We don’t know that. That in itself is worthy of research. Why don’t they know or why do they claim they don’t want to know or why they claim they don’t know? That is another question, but what they need to realize is that the only reason we have a profession is because of policy. We wouldn’t have one at all. In any given session of the legislature in the General Assembly in North Carolina or wherever you are, that profession could be taken away if you are not actively engaged in making sure that you’re protecting the practice rights that we have, expanding them where it’s appropriate, and standing up so that you make sure that everyone has access to health care. So for someone not to understand that, really strikes at the heart of who we are as physical therapists. Like we can’t fully say you know I embody and stand up and advocate for you know physical therapy and for people having access to it if they don’t understand that policy is the only reason we have a profession. We have to advocate.
49:41 Dr. Melissa Hoffman: Now where we are today is due to just that. That has been what’s created the change. For us to be where we are even today, you know, in the world of physical therapy. But there’s so much more.
49:53 Dr. Ginger Garner: Yeah that’s right, we’ve got so far to go, but at the very base level you know if we hadn’t fought for dry needling we would have lost dry needling. If we didn’t fight for spinal manipulation. We’ve had direct access in North Carolina I believe since 1986, one of the first states to have that. If they’re taking that for granted they don’t realize that came through policy. So policy is extremely important and we do have a long way to go, but I guess my take home message, like if we could encapsulate. I could keep talking to you guys for so long. This has been such an amazing conversation but I also don’t want to take up your entire afternoon.
But I want to talk about action items before we leave, because that’s my kind of M.O. as a person. Like let’s talk about the problem, okay let’s talk about an action item that we can list that we can make with three or four things on it.
So kind of two different questions you can kind of pick or choose either one. My last question is what would be an action item to take out of the chapter, that a PT could take (or not a PT could take) when we’re talking about health disparities. That’s one option for that question.
Or another option is what can people do in general to support people who are historically marginalized and treated poorly and discriminated against?
So I hope I didn’t jumble the two questions together too much. One is what can you take out of the book chapter as an action item? And then what can we do in general to support these communities?
51:39 Dr. Melissa Hoffman I think it’s so important to really understand because I just don’t think enough people understand how much opportunity and what resources are available through their own association. So I think educating yourself about what’s available at a more broader perspective. So you know I think about our communities, sexual and gender minority communities. We have PT Proud.
So PT Proud started out as just this little catalyst group that was run by students quickly moved into a committee. Then it was operating as both a committee for a budget and a catalyst group for membership and just recently in December, we graduated to a special interest group. So we’re now a say. But this is a great place for individuals to come for resources or to get involved. We have so many different subcommittees, we have podcasts and webinar, which is now programming. We have membership where you just learn the ins and outs of the business per se. We have advocacy, which has been very, very, very busy in the last two to five years, but we have advocacy.
So there’s lots of opportunities for education and resources so education is huge and there’s a number of other groups similar to ours within your own association. So really understanding what are the resources, what are the groups that are available for you to collaborate and work with a team to help to solve these problems. Because you’re not going to solve the problems by yourself. It doesn’t happen that way, you have to work with other people to solve the bigger problems.
53:21 Dr. Ginger Garner: Yeah I would make a plug for, since we’re talking about advocacy and policy because that shapes our profession, whether we like it or not. Because they do hold the keys to what we’re able to practice and do is to know who your legislative chair is in your state and ask them what their priorities are. I could tell you what our priorities are in the state of North Carolina as the legislative chair, but the committees are often you know small they can be even a committee of one in a state you’d be surprised at how much work a single person ends up getting saddled with as a legislative chair for the entire state.
And just knowing that someone is there to say hey i’d like to be the liaison if anything comes across your desk with respect to ABC health disparity. Would be really important because that might make the difference between a bill getting passed and or overlooked. That has to do with our profession and people accessing care.
54:22 Dr. Karla Bell: Absolutely. I’m going to bring us back to your individual level, your interpersonal level. You know, recognizing that the health outcomes and incidences of diseases and conditions are significantly inequitable for some populations and demographics, right. And that in itself is a starting point to help inform the way we practice. What I mean by is the way we approach patients, the way we need to truly be critically conscious (look that up if you don’t know what that means) of how the way we practice matters to health outcomes.
I think people kind of sort of think that, but they really don’t get it. Underrepresented populations, you know, historically traumatized populations, minoritized populations are front and center of these inequities and we gloss over these non clinical skills that you need to have continuing and lifelong learning about. Things like cultural humility, cultural competency, which is together cultural compatibility. But these things, the very systems that we have set up in society for healthcare delivery are in equitable and in the implicit biases in each of us. We have as practitioners help perpetuate the disparities.
So for us, the action item here is to really reflect on your worldviews and how that informs the way you practice. We have to understand that the patient’s lived experience related to their experiences of their identities, it matters to their health status. It’s part of the contributor to their health status, the experiences they have related to their various identities right. It’s not just the clinical skill sets that we hold that make the difference, and so the action here again is you know. In fact, the clinical skill sets, these are not as front and center important as the way we approach patient care. back to this you know integrative medicine and lifestyle.
Like we approach patient care, our cultural responsiveness and setting up cultural safety. The kinds of patient education we’re doing. The incorporation of the social determinants of health and understanding the political determinants of health and how it’s informed on the health status of the patient in front of us. That stuff needs to be done. We need to do a lot of interpersonal work. We all do. Because again we just talked about how our DPT entry level education didn’t do this, and I would argue it still really doesn’t do a great job. So that’s my plug.
57:15 Dr. Ginger Garner: Yeah so well said, and I agree, because if the DPT programs were covering it, then we wouldn’t we wouldn’t need this [holds up the ILM in PT book.] You know we wouldn’t need to be talking about it, because it would be done. And it would be implied. We would understand that, yes, this is what we do, but it takes conversations like this, it takes doing the research, it takes presenting at conferences. It takes reaching out into our own communities and letting people of marginalized communities know that you’re welcome here in our practice.
And if you can’t afford it, I know at our practice, we will help you find a way to see us. We will help you find a way. There are colleagues, I take some pro bono clients. I’m a cash based practice. Not because I went into it to make a bunch of money, but because I worked with a chronic pain population that insurance wasn’t paying for anyway, so I had to be creative and find other ways to provide care, so if you’re listening and and you want care and you don’t know where to get it.
Reach out to your state association and ask them, they will have information for you if you happen to be in my state. You can certainly reach out to our state association. You can certainly reach out to any of us on the podcast in their respective states, because our goal is to help you find care. So if you’re listening and you’ve experienced some of the things we’ve talked about, we definitely want to help.
This isn’t just talking about it and going home. We actually want to see the needle move and not have to be talking about this in another decade. You know, so that hopefully things will be different.
One last question I have for you is if someone let’s see Melissa you’re in Colorado. Karla you’re in Pennsylvania, right?
59:08 Dr. Karla Bell: So I’m part of two chapters. I live in Delaware. So I’m part of Delaware and so part of Pennsylvania okay. So if someone is in that you know location region and they want to reach out to you, how do they get how do they get in touch with you guys.
59:25 Dr. Melissa Hoffman: I think the easiest way is our emails. They are front and center. I’m at Regis University. You can go to the Regis University Doctor of Physical Therapy page for the faculty and find my email. So I think we have some phone numbers that are available. You can find me also through PT Proud. The PT Proud SIG through the Academy of Leadership and Innovation. I serve as chair of the PT Proud SIG, so all contact information is there as well.
59:59 Dr. Karla Bell: And same for me I’m at Thomas Jefferson University. So you know Google me as faculty my emails right there Karla.bell@Jefferson.edu. You can find me on Twitter @passionatePT.
01:00:14 Dr. Ginger Garner: All right, thank you guys so much. If you’re listening and you have your own podcast or you are doing you know information in the the journalistic world and want to interview these wonderful people, you should. So that’s how you get in touch with them.
If you have questions about access to care or research or just you know those types of questions, those are all good things so please reach out and we’re all glad to help you.
Thank you, Dr Bell. Thank you, Dr Hoffman for joining me today. This was one of the most important conversations I think that I’ve had in my career and I just want to encourage everyone out there to keep seeking out that information for awareness and advocacy, because if we all do a little bit we can make a massive difference to push this conversation forward.
01:01:05 Dr. Karla Bell: Absolutely, thank you.
01:01:08 Dr. Melissa Hoffman: Thank you everybody.
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