How can we address disparities in the delivery of healthcare? In this episode of MossRehab Conversations: Therapy Edition, Trish Crane, PT, clinical manager MossRehab Plymouth Meeting, and Jazmine Tooles, PT, DPT, a physical therapist at MossRehab's Drucker Brain Injury Center in Woodbury, NJ, discuss how MossRehab works to reduce bias and improve healing through culturally competent care. 

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Welcome to another episode of MossRehab Conversations, Therapy Edition, where clinicians at this nationally ranked physical rehab facility come together to discuss their expertise. The topic this time, diversity in physical therapy. We join Trish Crane, clinical manager at MossRehab Plymouth Meeting and faculty member in the orthopedic PT residency program as she speaks with Jazmine Tooles, a physical therapist with MossRehab’s Drucker Brain Injury Center in Woodbury, New Jersey where her focus is outpatient traumatic brain injury, stroke and orthopedics. Tooles is well credentialed and passionately involved in diversity initiatives. She serves as chair for the American Physical Therapy Association of New Jersey's Cultural Diversity Committee, Pennsylvania Physical Therapy Association's Minority Affairs Committee and leader of MossRehab’s Cultural Diversity Special Interest Group.

Thank you for joining me today Jazmine to discuss issues around diversity in therapy. You have been very busy spreading your message and helping your peers understand the impact of diversity on the delivery of therapy. Can you tell me about your work and how you became interested in this topic?

Because I'm mixed, people are always questioning my race or ethnicity, so diversity is a topic I really can't escape. Both of my parents are actually by-products of interracial marriages during the civil rights movement. So growing up for example my mom used to tell me stories about living down south and being mixed and being called zebra because she was mixed. When I specifically got really involved in diversity initiatives within the profession of physical therapy back in 2017, I was attending a conference and I found out that the American Physical Therapy Association actually had a minority affairs and women initiatives department and that I could start diversity committees at the state level. So I did that, and from there it's pretty much taken off since then.

So Jazmine what exactly is diversity?

Diversity is basically a term used to explain that there's variety between people. There are differences between people and those differences are shaped by our experiences and our experiences can be shaped by our family, by our friends or just different life experiences that we may have. I think an important thing to understand about diversity is that it's our ability to kind of recognize the differences between people and acknowledging that those differences are actually assets versus negative.

So when discussing diversity, there are terms that can often be used interchangeably but actually have very specific definitions. So I thought it would be helpful if you would define a couple key terms so can you spend some time telling me what the difference between race and ethnicity is?

It’s actually one of my biggest pet peeves because I feel like race and ethnicity is often used as the same word and they have completely different meanings. Ethnicity is the state of belonging to a certain social group that has common traditions or cultures. So for me, ethnically I'm African American, Native American, Greek, Danish and Irish and a couple of other things. So those are different cultures that I come from that are in my family. Race however is more of a social construct that groups people based off of physical qualities, primarily your skin tone. Basically are you light skin or are dark skin? And that affects how people treat you and how you’re categorized. So for me, though my ethnicity is all those different things, my race is considered biracial.

What are some of the challenges that you've encountered or that you see in your everyday work with regards to diversity?

First and foremost, healthcare itself is not very diverse and I think healthcare is kind of a reflection of society in a whole. You know the disparities that we see in healthcare are the disparities that we see in many aspects of life. In my personal experiences just being in the clinic, I often see that a lot of clients, especially those who are minorities, aren't able to find providers that they feel like look like them or they feel they can relate to. So for me I find a lot of patients are more willing to share certain information with me or are willing to be more compliant because they feel like they can relate to me and that we're working towards the same goal. I also see that because of the history of historical oppression and experimentation in healthcare, there's a lot of distrust between certain ethnic communities and healthcare, which you can totally understand. On the other hand I also see that since there aren't a lot of minorities in healthcare, there's a burden that they take on as well. A lot of minorities in healthcare have to deal with racial microaggressions by co-workers and patients. Racial microaggressions are like verbal or behavioral actions, intentionally or unintentionally, that communicate derogatory or prejudice flights toward marginalized groups. So an example of that for me is sometimes I find that I'll have to, like, when I meet a patient for the first time, they'll want to know a little bit more about my background, you know, where did I go to school? How long was I in school? How long have I been practicing? But they won't necessarily ask that to my counterparts. Another big thing that I notice because I’m mixed and I have fair skin, people are always questioning what my race is, like they'll ask straight out like, oh where are you from? Is your family from here? And then finally another big thing that I've noticed in healthcare is the inequity that you see amongst healthcare facilities and clinics based off their zip code. So you see that clinics and healthcare facilities are expected to perform to the same standard, but don't necessarily have the same resources. They might not have the same staffing, they might not have all the same equipment, or up to date equipment. The accessibility of the building is different, the parking is different. So all those play a role in the healthcare that we're able to provide. So those are just some of the things I've just noticed in my experiences over the years.

So based on those findings, how have you been working towards making the care provided at MossRehab more equitable?

It’s a long slow process, but I've been fortunate because MossRehab has been really open and receptive to a lot of the diversity initiatives that I've been trying to work on and Moss already has so many things integrated into our healthcare system that I don't know necessarily exists other places. For example we have a cultural development specialist. They do a lot of community outreach programs such as Discover Healthcare. We have the Martin Luther King Day celebration awards. For CARF, we have the cultural competence and diversity plan that has to get evaluated every couple years. We have the pride program and one of the great things that we have is the interpreter services which I don't think is a service that everyone is fortunate to have in other healthcare facilities. Also I've been overwhelmed by the support that I received from senior leadership. So I've had discussions with the President and Chief Operating Officer about the work of the cultural diversity special interest group which I'll talk a little bit more about. That group actually would not even exist without the support and suggestion of the director of therapies. So to answer your question, the way we're trying to provide more culturally competent care is actually through our MossRehab cultural diversity special interest group. So this group started in 2018. It's comprised of therapists in different specialties throughout the network and within different facilities. We meet once a month. Some meetings focus on ways we can do community outreach to increase awareness of health careers to diverse groups or we figure out ways to promote cultural competence in the network whether that's through education, email blasts, or through our cultural competence journal clubs. Next actually we will be discussing racial microaggressions. Defining what that is, what it looks like, and teaching people how to manage it if they're receiving racial microaggressions or if you're a bystander, how can you be supportive of your co-worker when you see that they are dealing with the microaggressions. The members of the SIG are all great clinicians. They're really dedicated to tackling this really sensitive topic. Every meeting we have great open conversations. It’s still a work in progress. People have lots of ideas and we're just trying to find ways to streamline it and spread what we're learning throughout the network.

Have you gotten a lot of support from your peers?

Oh yeah definitely. Especially my home base here at Woodbury. We have a lot of open discussions about race and diversity and experiences we might have with patients because we know sometimes patients can have their own biases and that might impact how they react to us, what they're willing to share or what they're willing to comply with.

So what I found most helpful from the work of the special interest group that you lead is becoming a little bit more aware of my own biases which is a little bit of a funny thing because we're not often aware that we have a bias. Do you find that you have your own biases when you're treating and how do you handle these situations?

Yeah definitely. That's the thing about bias. Sometimes it's intentional. I think a lot of times it's unintentional because again, our biases are shaped by our experiences, right? I've been fortunate because I come from a mixed family that I've been exposed to a lot of people. I came from a very diverse town, so I've been exposed to a lot of people. But I still have my own biases. One of my main biases is when it comes to elderly white males, especially those who may suffer from like cognitive changes or dementia and have lost their filter. As a clinician I know I need to always remain professional but also be able to set boundaries to optimize our patient provider relationship. So one of my fears, or I guess a part of my bias is when those individuals come into the clinic, I'm not sure how they're going to receive me, whether they'll be receptive to working with me or the things that I say. And since I'm the only physical therapist at our location, it's either me or no one, so it's important that I'm able to have a connection with every person who walks through the door. I often lean on my co-workers to have opened up conversations about their experiences with the patient because I also recognize that not everything is racial. So since I know in my mind I already have that preconceived notion that they might be biased against me, I'm kind of being prepared for it. But I also need to understand that that's not always the case. So, little things like if a person comes in, I’m meeting them for the first time and they want my whole resume, you know, where did you go to school? How long have you been doing this? I'll ask my co-workers who also evaluated them, did they ask you these same questions too, or was it just me? Because that's kind of giving me an idea and like is it just me being paranoid or are they trying to see if I measure up to the standards in their mind because they see that I am a different race. A specific example that I'm thinking of now is a couple of months ago we worked with an older gentleman who had a stroke and was having cognitive issues and he was one of those guys who came in and he was asking me a whole bunch of questions because he'd wanted to make sure I was qualified to treat him, which is you know understandable, but he didn't ask that to anybody else who worked with him. So that already perked up my ears that we might have a few issues. And then during our sessions he would become very impulsive, partially because of the cognitive changes and he would try to leave the facility when I was working with him and he wasn't so forceful about it with other folks. So I was trying to figure out like, okay, is it me? Does he feel threatened by me? What is it? Thinking about it and talking to the rest of my co-workers, it did come out that he did have some racial biases, so race was somewhat of a factor and also little things like it ended up working out when I would work with him, nobody else would be working with someone at the time and I guess that made him uncomfortable. So after kind of sorting through that I realized, okay, let's always make sure somebody else is treating when I'm working with him. Little things like making sure I'm not blocking the exits because he sees me as a threat. And then even just restructuring our sessions the order that I did exercises kind of helped change it. So that's just an example that comes off the top of my head. Luckily this isn't a norm, but I do realize that it is a reality and I have to be mindful of those situations. But usually my co-workers are the biggest supports and we're able to work it out and hash those things out together.

Your examples seem to point to trust between the medical provider and the patient that allows for that therapeutic alliance to present as a barrier. How can we as clinicians break through this barrier to ensure that the care provided is optimal?

That's a tough question. I don't know that there's like a straightforward answer to it. I think though the first step is trying to really have those genuine conversations with clients and get an idea of their whole story and like, really listening. I know with reimbursement changes, we're really constrained, but it's a necessity. We need to be able to make goals based off what the patient values, not just what we think is important. What I think is important is not necessarily going to be what that person thinks is important. And I think the second step is exposure. Unless we take the time to be around different people, we only make decisions based off of our limited exposure. If you think how many clinicians may only engage with certain ethnic groups at work in the healthcare setting because maybe their homes or communities are not necessarily as diverse as the populations that they're serving. So, think of the bias that can be generated when you only work with a certain ethnic group when they're sick, irritated and vulnerable, right? You're not going to have the best impression of them. Your whole perception of a group could be skewed by just being exposed to a group only at their worst. So I think having open conversations and making goals based off the patient's values, not just your own, and also taking the time for personal growth and exposing yourself to people that are different from you.

You mentioned that there's not a great deal of diversity with regards to healthcare providers. So I would assume that this holds true of applicants to various schools with physical therapy school being an example.

So healthcare in general is not very diverse. We are seeing some increases in diversity in some health careers but there's minimal to no increase in diversity in leadership positions, so that's one thing. For physical therapy specifically, the US Census is roughly 60 percent white, non-hispanic and then 40 percent other minority groups so Hispanic, Asian, Native American, Hawaiian, Pacific Islander, Black African-American and biracial. But when you look at physical therapy, the distribution is 80-20. So that's a significant difference. And then when we look at physical therapy programs, there is a low number of minority students applying to PT programs, but we also see that even so, still a higher percentage of white students are accepted in the program compared to the few minorities that are applying. So that's something that a lot of PT programs are starting to look at. One, that a lot of people are aware of the profession, so we're trying to work on ways to increase that, but also schools are starting to look at the admissions process. So for example, one of the things schools are looking at are the GRE’s which is known for having racial bias in the testing and actually not being reflective of a student's ability to succeed in the program or pass their boards. So schools are starting to look at whether they should even count the GRE or if they do count the GRE, how much weight does it really hold.

What's the most exciting change that you've noticed in the MossRehab Network since you started the diversity special interest group?

I think the most exciting thing, because it's still very young or new, I think what's been exciting is the number of ideas that have developed from it. You know it started just with okay, why don't we have a special interest group where we can talk about this stuff. But I wasn't really sure where it would go from there. Like what would we be doing? So some of the ideas that have evolved are trying to do community outreach events, we're looking at the patient intake forms and seeing if there's ways to reformat them or add little questions that help give more cultural competence information. For example certain groups can come to the clinic at certain times because of the holiday like they have to be home before sundown or certain religious holidays, people can't come in. So being aware of those things can help someone plan their course of care. Some other things that have developed over time are we now started a word of the month where we share the definition of a diversity term and then provide a real world application. So January we sent out an email defining diversity as I discussed with you earlier and then the real word application is you know are you actually asking the question on your evaluation form. Are there any cultural or religious things that we need to be aware of to incorporate into your treatment. So the exciting thing is, like I said, so many ideas are coming out from the different members and you find that people are doing little things on their own. So we're just trying to find a way to expand it and work together and reach more people.

I have to say firsthand that that e-mail and those tips have really sparked conversation and I really think that's a huge aspect of breaking the barriers is just talking about the fact that these biases exist. What advice do you have for other therapists on how to approach diversity issues that they might encounter?

Nothing's ever predictable, so it's hard to say an exact way to go about it. I think going back to what I mentioned before, the first step is just taking the opportunity to expose yourself to people different than you and not just at work. Maybe volunteering or just trying something different that you really wouldn't that exposes you to a different culture. And then I think the second step is talking to your co-workers about it and it doesn't have to be a co-worker who is a minority, just anyone. Talk about what you’re experiencing and kind of try to problem solve together. Because again, even amongst cultures, there's big differences even within each culture. So there's never a straightforward answer to anything, it's just being open to having the conversation and being open to thoughts that are different than your own.

Thank you so much Jazmine. You are certainly making a difference in not only the MossRehab Network, but in the profession as a whole. So it's been an absolute pleasure talking with you today and learning more about diversity. Your education has certainly changed the way I think and treat. So I really appreciate all of your hard work and dedication.

Thank you.

That was Jazmine Tooles, a physical therapist with MossRehab’s Drucker Brain Injury Center in Woodbury, New Jersey where her focus is outpatient traumatic brain injury, stroke and orthopedics. Also on the web at mossrehab.com/conversations you can listen in as we talk with pioneers in physical medicine from around the globe. I'm Bill Fantini. Thanks for joining us on MossRehab Conversations, Therapy Edition.