Expanding the Boundaries of Care

When it comes to providing patients with optimal care, physical therapists must consider social justice and equity issues as major components of treatment while also teaching the next generation of practitioners of its importance.

That was the message at “Connecting Physical Therapy Practice, Social Justice, and Health Equity,” the recent day-long event hosted by the MGH Institute’s Department of Physical Therapy.

“As physical therapists, it’s vital that we stay engaged with social justice issues,” said Dr. Keshrie Naidoo, interim chair of the school’s PT department. “We must face the discomfort, speak the truth, and expect and accept non-closure. In other words, as therapists we should be prepared to hang out in uncertainty and not rush to quick solutions, especially in relation to racial understanding. It is through dialogue that healing and change begin.”

More than 60 people from around the country attended the September 30 virtual conference. They heard from an array of physical therapists – many of whom are IHP graduates – on topics including homelessness, how where a person lives affects their lives, racism in maternal care, and trans and diverse gender care.

She said the conference was in part due to the role the Institute’s Justice, Equity, Diversity, and Inclusion (JEDI) initiative and the role it plays throughout the curricula in all the school’s academic programs. “The Institute’s commitment to JEDI has been impressive,” said Naidoo, who credits both students, faculty, and senior leadership for the successful implementation of JEDI principles into the IHP’s curricula.

Naidoo, who grew up in South Africa during apartheid, is especially attuned to social justice issues. “My first clinical appointment was in a South African hospital just a few years after apartheid ended, so I saw first-hand the inequities inherent in that healthcare system.” This insight led Naidoo to create a social justice and health equity cross-curricular thread in the DPT curriculum and organize and host the conference for the PT department's clinical partners.

Know Thy Neighborhood

Dr. Justin Wong, an orthopedic clinical specialist at the Spaulding Outpatient Center in Malden, stressed the importance of therapists knowing the neighborhoods that surround their practice and the social justice issues that affect those patients.

“Many PT professionals will discuss social justice and equity issues in the back room,” said Wong, who completed the MGH Institute’s Orthopaedic Clinical Residency and currently is a lab instructor in the PT department. “The phrase I hear a lot is ‘this patient has a lot going on.’ It’s a euphemism for a serious health problem caused by a social issue that a therapist may not know how to address. That phrase gives us an easy way out and must be avoided.”

He pointed out that health behaviors like smoking, diet, exercise, drug and alcohol use are not always the top factors affecting health, saying it’s important to at what resources are available near their clinical practice, such as housing assistance programs, farmer’s markets, food banks, mental health services, even YMCAs. “We now know that a person’s zip code can be a key indicator of health,” he noted

Home is Where the Heart Is

Dr. Lauren Rimmel focused on the profound effects of homelessness. Rimmel said Covid-19 opened her eyes to the inequities in the health care system, as homeless patients were often overlooked during the pandemic.

“When you study homelessness and health outcomes,” said Rimmel, an adjunct faculty member at the IHP, “you soon realize not only the complexity of the issue, but also the many weaknesses in our safety net.” Rimmel pointed to Tracy Kidder’s book Rough Sleepers as a must-read that delves into weaknesses in healthcare system,  public health education, housing, criminal justice, and welfare systems

Rimmel shared research that showed the aging effect of homelessness, as patients who are homeless often develop geriatric issues much earlier than the general population. “We even see health issues with young people who couch surf for long periods of time,” said Rimmel, who reminded attendees that physical therapists often know patients better than their primary care physicians simply because they see them more often and thus have a responsibility to ask about life changes and the risks associated with those changes. “Be brave enough to ask the tough questions like, ‘Do you have a place to sleep tonight,’” she said.

Bulit Environments and Health

Dr. Valerie Rucker-Bussie, founder of Priority One Wellness in Washington, DC., and adjunct faculty at the IHP, spoke next and focused her presentation on three key areas of social justice: the relationship between zip codes and health, the impact of built environments on health, and action steps for change.

Rucker-Bussie began by sharing a resource that tracts life expectancy of specific zip codes and pointed out how data often corresponds to race. She pointed to how highways built in the U.S. between 1950s to the 1970s were intentionally designed to segregate minority neighborhoods from other communities. Living in the shadows of highways resulted in higher rates of asthma, leukemia, and early death, and often created food deserts in these highway-adjacent neighborhoods.

“When you add up the stress that afflict certain segments of America—economic stress, segregation, racism, air pollution, poor diet—you will encounter a host of health issues in those patients, and as professionals we need to be aware of the social issues that cause them,” said the 2018 Doctor of Physical Therapy graduate.

Rucker-Bussie pointed out that minoritized and marginalized populations also suffer from a lack of green spaces in their neighborhoods, and for many, it’s not even safe to exercise, pointing to the murder of Ahmaud Arbery while out jogging.

“We’ve seen an increase in violence and threats of violence against people of color,” said Rucker-Bussie. “As professional therapists we need to be aware of these issues and how they affect health. We also need to pro-actively work to address issues like racism, as we know its detrimental effect on health. Racism won’t end overnight, but now is the time to demand change.”

Physical Therapy is Birth Work

Dr. Kamaria Washington said the United States has nearly three times more maternal mortality than the next closest country, France, and nearly eight times the rate of Germany and the Netherlands. She said statistics are even worse for Black and African-American women, who are three to four times more likely to die from pregnancy complications than White women.

“These numbers are alarming, but research shows that a woman’s race is not the reason for these depressing statistics,” said Washington, founder, CEO, and lead therapist and educator at Pelvic Noire Physical Therapy & Wellness in Detroit, MI, and a 2021 DPT graduate of the Institute. “Instead, systemic racism and the lack of quality care for people of color is the driving factor.” She added, “Our society has a bias that affects judgments, decisions, behaviors, and the distribution of resources—and women of color pay the price.”   

Washington stressed that physical therapists can provide patients with information on such things as pain management, bias training, joint mobility, lymphatic drainage massage, books on birthing, and refer them to community resources. “Even finding local resources to deliver groceries can make a difference,” she Washington. “But most importantly, we need to educate ourselves to recognize bias and speak out, including biases in ourselves that we might not recognize.”

Trans and Gender Diverse Care

Dr. Keelin Godsey discussed health issues affecting transgender people, though he was quick to point out that transgender is an umbrella term that includes a variety of gender diverse people. Godsey, coordinator at Johns Hopkins Sports Physical Therapy Residency program, talked about how most people, including healthcare professionals, are often unsure of gender terminology.

“Avoid using gender-specific terms whenever possible,” he said. “And if you’re unsure of a person’s chosen name or pronoun, then ask. Never assume. Only ask for information that is necessary for the care you are providing. If you need to discuss gendered anatomy, be advised that this may cause discomfort so you should approach the topic in a sensitive and respectful way.”

He identified a wide range of healthcare challenges that transgender and gender-diverse people face. “For instance, 42 percent of transgender people attempted suicide during their lifetime, compared to eight percent in the general population,” said Godsey. “Eighty percent report discrimination when seeking a job, and about 50 percent report discrimination or negative experience by healthcare providers.” Such discrimination appears to cause twice the normal rate of chronic depression, and about a third of transgender people have experienced homelessness in their lifetime.

Godsey discussed different gender-affirming treatments specific to transgender women and transgender men, including, the potential health complications from these procedures. “Physical therapists should understand all the gender-affirming options available and how each option can affect the health of each person,” he said.

For attendee Noam Segal, clinical director of Physical Therapy at MGH Chelsea, the conference reinforced his professional values and the work he’s doing on creating a module to help clinicians handle micro-aggressions.

“This conference helped me identify ways that my team can build stronger relationships with our diverse clientele,” said Segal, who graduated from the Institute in 2014. “The more exposure a therapist has to the inequities in health care, and the inequities that our clients face, the more tools we can give ourselves to address them.”

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