Racial Disparities in Physical Therapy
A 2015 commentary in the American Journal of Public Health defines racism as a “system of structuring opportunity and assigning value based on race that unfairly disadvantages some individuals and communities”. In other words, racism is deeper than the outwardly facing vile acts one person commits to another. The various ways that our societal structures have made life less equitable for some than others have been uncovered in great depth in recent weeks. We discussed this in broad strokes in our recent blog “Social Determinants of Health: How Privilege Affects Health Outcomes”. It’s no secret that healthcare in the United States is far from innocent in that regard and many experts in the field are doing what they can to bring about positive change. In fact, the same commentary in 2015 admits that “public health, at its core, is antiracist work.”
As deep as we would like to go on this topic, we want to specifically point out the ways that our profession has contributed to the inequitable access to physical therapy for Black people in this country. Similar to our approach with patients and clients, before we can fix a problem we must identify the contributors to it.
Representation
Representation involves using people or symbols as a stand-in to be the voice of familiarity for others. According to 2018 statistics, only 3.67% of the 249,500 physical therapists surveyed were Black. Asians made up the second largest group at 12.9% and Whites were the largest group at 80.4%. As far as the educational data is concerned, the Physical Therapy Centralized Application Service (PTCAS) reported that only 6.14% of the 18,359 physical therapy school applicants in 2018 were Black.
This discrepancy in representation at the professional level undoubtedly plays a part in why Blacks are also underrepresented in physical therapy school applicants each year - one is less likely to pursue a career if they have not seen someone from their community in that position before. Representation is a crucial factor in healthcare as patients need providers who can empathize and understand them on a deeper level. Often, that understanding starts with having a similar skin tone.
The fact is, we need more Black physical therapists in healthcare.
Race, pain, and pain management
A 2016 National Health Interview Survey found that Blacks had the second highest prevalence rates of chronic pain at 17.9% of the population. Despite that, the more common methods of pain management available to the general public are either underutilized by Blacks or are just not as accessible by the Black community.
An analysis spanning from 1979-2010 showed that while Blacks died at a higher rate from opioid and heroin usage in 1979, by 2010 the White community and the Black community had reversed roles to where Whites were twice as likely to be given a prescription to opioids than Blacks. Some have questioned whether this silver lining is due to a combination of marketing tactics by pharmaceutical companies targeting rural White communities and a lack of health insurance and routine healthcare visits to doctors in Black communities. A study done in 2016 also showed that medical trainees had an underlying bias towards Black patients that they may feel less pain due to a perceived thickness of their skin. While it is unlikely that this particular belief is actually being taught in medical schools, anyone who has worked in medicine and healthcare can tell you that tradition and long-held, unsubstantiated beliefs run rampant in clinical training.
Physical therapy utilization
A 2017 study found that Hispanic and Black Americans are 26.5% and 44.8% less likely to attend at least one physical therapy office visit in a year for self-reported arthritic conditions, respectively. In other words, there is a much higher chance if you are White that you will attend a physical therapy clinic for arthritis related pain in a given year. Now, there are some obvious shortcomings of a study like this from our perspective but it does highlight that by and large most patients in outpatient physical therapy are White. Here is a list of possible reasons why this might be:
Lack of Black representation in physical therapy providers. Again, this is important because patients are most likely to seek out providers that they can immediately relate to. For example, most athletes want to work with therapists that were or are currently participating in sports themselves.
Fewer routine visits to primary care providers by Blacks likely contributes to fewer physical therapy referrals in states where doctor referrals are required.
Blacks and Hispanics continue to be the two most uninsured races, despite increases in insurance rates from the Affordable Care Act.
Physical therapy clinics tend to be in communities of affluence with nuclear family stability, higher household incomes, and higher rates of insured residents.
Other healthcare considerations
While not directly related to outpatient physical therapy, Black Americans also suffer from higher rates of hypertension, nutrition deficiencies, and chronic stress. While these issues are the result of multiple layers of issues, the fact of the matter is that healthcare by and large is a great contributor to the racial disparities and inequities in our country. The system of healthcare functions on tiers of access and privileges. As a result, the people that comprise the system are assigned a value based on those tiers.
Our position is that healthcare as a whole needs to change from the inside out. If we can’t truly provide care for all of our citizens then calling it “healthcare” seems rather contradictory in our opinion.
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