Our nation has been shaken, awakened from a long slumber in which many of us dreamed that we were close to a postracial state. More than a half century after the Civil Rights Act of 1964, the year 2020 showed us that we have much further to travel to achieve racial equity in this country. Within weeks of the first cases of COVID-19 being recorded in the United States, Black, Latinx, and American Indian people were facing stark disparities in their rates of infection and death due to the virus.1 At the same time, the murders of Ahmaud Arbery, George Floyd, and Breonna Taylor sparked national and global social unrest demanding that society recognize that Black lives matter. In response to these events, we saw in our inboxes a flood of statements of support that denounced hate and pronounced racial injustice unacceptable. Although such statements might be evidence of good intentions, words are not enough. Organizations, both public and private, must address the policies and systems that allow racism to continue to infect our social structures.
In this Point of View, we call attention to the presence of racism throughout the organizations and systems that make up the physical therapy profession in the United States. We argue that our statements of support must be substantiated by actions that drive change throughout physical therapy organizations. Finally, we briefly describe how our own organization—the Division of Biokinesiology and Physical Therapy at the University of Southern California—has come face-to-face with its responsibility to confront its own institutional racism, and we suggest strategies for initiating change toward becoming an antiracist organization.
Problem: Racism Within the Physical Therapy Profession
Over the last few decades, overt interpersonal racism, although still prevalent, has become socially unacceptable in the United States2 (see definitions of racism in Fig. 1). At the same time, systemic racism persists and has devastating impacts on health care and quality of life for people of color.3 Systemic racism is less obvious and more difficult to identify than interpersonal racism, and its effects are often framed to suggest that inequities exist not because of prejudice or bias but because of deficiencies inherent in one group compared with another. Yet, systemic racism in health care is apparent in American medicine’s history of abusive and dehumanizing experimentation and medical malpractice, its use of eugenics to rationalize such practices, and its reframing and selective silencing of such history.4 This racism continues into the present day with manifestly inequitable health disparities. Numerous studies report differences in quality of care, misdiagnoses, and reductions in referrals to specialty services for Black, Latinx, Asian American, and American Indian people.5,6 We believe that the lack of racial, ethnic, and gender diversity in the professional organizations of health care practitioners, researchers, policy makers, administrators, and educators who influence and shape the important decisions that impact health care and society is further evidence of systemic racism.
Definitions of racism.24–26
Representation of Different Racial/Ethnic Groups Among Licensed Physical Therapists, Physical Therapist Students, Core Faculty, and Academic Program Directors (2018 Data)
| Race and Ethnicity | Licensed Physical Therapists (2018)7 | Enrolled Physical Therapist Students (2018)13 | Core Faculty Members in Accredited Physical Therapy Academic Programs (2018)13 | Program Directors of Accredited Physical Therapy Academic Programs (2018)13 | Total US Population (2018)7 |
|---|---|---|---|---|---|
| White | 76.7% | 74.6% | 86.1% | 91.5% | 60.2% |
| Black | 3.6% | 3.4% | 2.7% | 3.0% | 12.3% |
| Asian | 12.9% | 8.9% | 5.9% | 2.5% | 5.6% |
| American Indian/Alaskan Native | 0.2% | 0.4% | 0.2% | 0.0% | 0.7% |
| Hispanic/Latinx | 5.3% | 6.5% | 3.3% | 1.7% | 18.3% |
| Other | 1.3% | 6.2% | 1.8% | 1.3% | 3.0% |
| Race and Ethnicity | Licensed Physical Therapists (2018)7 | Enrolled Physical Therapist Students (2018)13 | Core Faculty Members in Accredited Physical Therapy Academic Programs (2018)13 | Program Directors of Accredited Physical Therapy Academic Programs (2018)13 | Total US Population (2018)7 |
|---|---|---|---|---|---|
| White | 76.7% | 74.6% | 86.1% | 91.5% | 60.2% |
| Black | 3.6% | 3.4% | 2.7% | 3.0% | 12.3% |
| Asian | 12.9% | 8.9% | 5.9% | 2.5% | 5.6% |
| American Indian/Alaskan Native | 0.2% | 0.4% | 0.2% | 0.0% | 0.7% |
| Hispanic/Latinx | 5.3% | 6.5% | 3.3% | 1.7% | 18.3% |
| Other | 1.3% | 6.2% | 1.8% | 1.3% | 3.0% |
Representation of Different Racial/Ethnic Groups Among Licensed Physical Therapists, Physical Therapist Students, Core Faculty, and Academic Program Directors (2018 Data)
| Race and Ethnicity | Licensed Physical Therapists (2018)7 | Enrolled Physical Therapist Students (2018)13 | Core Faculty Members in Accredited Physical Therapy Academic Programs (2018)13 | Program Directors of Accredited Physical Therapy Academic Programs (2018)13 | Total US Population (2018)7 |
|---|---|---|---|---|---|
| White | 76.7% | 74.6% | 86.1% | 91.5% | 60.2% |
| Black | 3.6% | 3.4% | 2.7% | 3.0% | 12.3% |
| Asian | 12.9% | 8.9% | 5.9% | 2.5% | 5.6% |
| American Indian/Alaskan Native | 0.2% | 0.4% | 0.2% | 0.0% | 0.7% |
| Hispanic/Latinx | 5.3% | 6.5% | 3.3% | 1.7% | 18.3% |
| Other | 1.3% | 6.2% | 1.8% | 1.3% | 3.0% |
| Race and Ethnicity | Licensed Physical Therapists (2018)7 | Enrolled Physical Therapist Students (2018)13 | Core Faculty Members in Accredited Physical Therapy Academic Programs (2018)13 | Program Directors of Accredited Physical Therapy Academic Programs (2018)13 | Total US Population (2018)7 |
|---|---|---|---|---|---|
| White | 76.7% | 74.6% | 86.1% | 91.5% | 60.2% |
| Black | 3.6% | 3.4% | 2.7% | 3.0% | 12.3% |
| Asian | 12.9% | 8.9% | 5.9% | 2.5% | 5.6% |
| American Indian/Alaskan Native | 0.2% | 0.4% | 0.2% | 0.0% | 0.7% |
| Hispanic/Latinx | 5.3% | 6.5% | 3.3% | 1.7% | 18.3% |
| Other | 1.3% | 6.2% | 1.8% | 1.3% | 3.0% |
Although there are no specific studies documenting racial and ethnic disparities in physical therapy outcomes, we have to assume that a profession that is so overwhelmingly White7 (Table) will find it difficult to both recognize and correct systemic racism in the way its services are provided.8–10 Despite calls for increasing diversity for at least 2 decades,11 there has been no meaningful change in the representation of people of color in the physical therapy profession. In the 1999 to 2000 academic year, for example, Black people accounted for 3.2% of enrolled students12; in 2017 to 2018 they comprised 3.6% of enrolled students.13 Note that the United States has a population that is 12.3% Black.7 The lack of diversity looks even worse when we examine racial and ethnic representation among faculty in physical therapy academic programs,13 and worse still when we look at program directors13 (Table). When so few faculty and academic leaders are people of color, it is inevitable that physical therapists will be educated without a strong orientation to recognizing and correcting institutional or systemic racism.8,9,14 As noted by Livingston,14 “Providers with homogenous leadership teams and physicians who don’t reflect the communities they serve will find it difficult to address those social determinants and move the needle on racial and ethnic health disparities.”
Finally, although we have no definitive data regarding the leadership of professional organizations in physical therapy, it does not take much investigation to see that people of color do not have a seat at the table. Despite some well-intentioned attempts, our guiding professional organizations, the American Physical Therapy Association (APTA), the American Council of Academic Physical Therapy (ACAPT), and the Commission on Accreditation in Physical Therapy Education (CAPTE), have failed to provide effective actionable resources, guidance, and support to help the physical therapy profession increase its diversity, build an inclusive community, and address health disparities with our students who will become providers of health care. Indeed, the strategic plans, visions, and missions of these organizations do not adequately address these issues.15–17 In the 1980s, APTA attempted to address the lack of diversity in the physical therapy profession by establishing the Office of Minority Affairs and the Minority Scholarship Fund. The lack of change in demographics in the field over the past 20 years, as we have detailed above, is evidence that these efforts were insufficient. ACAPT and CAPTE have not yet attempted to develop mandatory standards for equity and diversity in physical therapy education programs. Although professional organizations in medicine, nursing, and dentistry have quantified the lack of diversity and established clear mandates for change,18–20 none of the physical therapy professional organizations have yet developed a comprehensive strategy to solve this problem. Indeed, we lack consistent data about diversity and equity in the profession, although the recent APTA Workforce study7 is a step in the right direction. To solve this problem, all physical therapy professional organizations will need to join forces to develop a coherent strategy to collect data, provide funding for intervention approaches, and evaluate the evidence regarding what programs or supports are required to increase representation and address disparities.
Solution: Addressing the Physical Therapy Profession’s Contribution to the Status Quo
Systemic racism persists because individuals, professions, and organizations blind themselves to its presence. The assumption is that “no news is good news.” If no person has complained or pointed out that racism exists, or if we don’t witness interpersonal racism ourselves, then we assume that racism does not exist. As we have demonstrated in this Point of View with support from the literature, the history of systemic racism in academia and health care, the lack of diversity among faculty and students, and the inaction of our professional organizations and education programs, clearly establish that systemic racism infects our organizations and institutions. The physical therapy profession’s lack of progress in the face of persistent inequity is evidence that it is part of the problem of systemic racism in health care and society.
When confronted with this notion, many individuals in the profession will dismiss it or reflexively enter into a state of denial. One reason is that White professionals do not see themselves reflected in the image traditionally conjured by the term “racist” (eg, white hoods, burning crosses, referring to people using derogatory terms). If professional organizations do not act in significant ways to change the status quo and help individuals identify the collective systemic racism within our profession, then they allow the continuation of implicitly racist policies and structures within professional education. Without change, physical therapy will continue to contribute to the perpetuation of systems in which the care provided to patients and communities of color is inequitable and deficient. This is how racism lives on.
To break the vicious cycle of systemic racism, academic programs and organizations within physical therapy must actively work to change at the institutional and professional levels. They must identify the root causes of inequity and lack of diversity in their own structures and policies, they must educate themselves about racism and health care disparities, and, most important, they must transform themselves into antiracist organizations.
Our Experience at the University of Southern California
Within the Division of Biokinesiology and Physical Therapy at the University of Southern California, we have long considered ourselves supportive of equity. We took pride in a community that we assumed was inclusive and equitable. Seven days after the murder of George Floyd in the summer of 2020, we invited faculty, staff, students, and recent alumni of the Division to a virtual forum to express themselves and provide support to one another during the height of the nationwide social justice uprisings. In this forum, with 230 members of our community present, the voices of fellow students, faculty, staff, and alumni expressed pain, despair, and anger about how racism affected their lives and their work. Racism was no longer about people on the television news or from the civil rights era. These were stories of our very own colleagues, students, and friends living through and feeling the pain of racial injustice. Listening without judgment and the reflexive impulse to deny was the essential act that led to understanding our need to address these issues. After this community conversation and several others that followed, we recognized that the work we were doing toward improving our demographics and being welcoming to all was not nearly enough. Without addressing our own institutional racism and its impacts on physical therapy education and care, we had no chance of fulfilling our Division's mission to “transform healthcare by creating the future in physical therapy.”21 We were educating, researching, and practicing in a way that maintained inequities and that did not “transform” health care in the most basic way necessary—to address the needs of all individuals in society. This period of listening to our community led to our collective realization that delay in addressing racial injustice was not an option.
A Commitment to Change
The recognition of our Division’s contribution to racial inequities and systemic racism prompted self-reflection and a search for resources. The lack of resources within the physical therapy profession was staggering. Although our program began to address our contributions, it was clear that physical therapy as a whole was at a crossroads.
As a profession, we can choose to ignore our contribution or we can choose to critically look at our policies, practices, and culture. If we are to “build a community that advances the profession of physical therapy to improve the health of society,” as stated in the mission of APTA, then we need to recognize our need for individual, organizational, and systemic change. We need to develop a plan that includes clear and measurable objectives. We need to determine evidence-based strategies that provide a clear roadmap of the actions that will sustainably move us closer to achieving the objectives in our plan. To aid in the success of this plan, we need to engage all stakeholders and develop consensus. Most importantly, we need to adopt an antiracist perspective. It is not enough to “not be racist,” because this reinforces our tendencies to be blind to racism and too easily permits passivity.22,23 To be antiracist requires action against the status quo. If we believe in our mission to “improve the health of society,” we must choose to bravely address a major contributor to the ill health of our society: systemic racism.
We invite our colleagues in the physical therapy profession to have the courage to move beyond being “not racist” and become antiracist. We have outlined suggestions in Figure 2 to prompt reflection and inspire action at the individual, organizational, and systemic levels of the physical therapy profession. We view these recommendations not as an exhaustive list, but as the starting point of a bold direction toward transforming society. Because the status quo and cultural norms will be challenged, there is risk in accepting this invitation. The physical therapy profession has had to accept risk and take bold steps before, as we ventured into new territories related to accrediting our own academic programs, changing degree requirements, and advocating for direct access. We are optimistic and motivated to be a part of the journey of becoming an antiracist profession. Greatness is rarely achieved by accepting things as they are.
Suggestions for initiating change, with examples of actions at individual, organizational, and systemic levels.
Author Contributions
Concept/idea/research design: N.D. Matthews, K.M. Rowley, S.C. Dusing, L. Krause, N. Yamaguchi, J. Gordon
Writing: N.D. Matthews K.M. Rowley, S.C. Dusing, L. Krause, N. Yamaguchi, J. Gordon
Funding
There are no funders to report for this article.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
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