Author(s): Maurice G. Sholas, MD, PhD
Originally published: July 17, 2020 Last updated: July 17, 2020
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Overview and Description

The discussion of disparate health outcomes is relevant to all practices of Physical Medicine and Rehabilitation.   Regardless of the setting (academic or private practice) or the area of focus (pediatrics, sports, chronic care, cancer rehab, interventional pain, or occupational health) it is essential that all patients fully benefit from the consultative guidance and interventions of Physiatry.  It is evident that our field is not immune to personal, institutional or systemic realities that bias care against key groups within our patient populations.  Thus, we must appreciate the literature on the topic and actively plan mitigation strategies to ensure the best outcome for all patients under our care.   This submission reviews the state of access to and outcomes from rehabilitation services through the lens of equity.  Individuals with disabilities are already marginalized. However, the addition of race and culture further disenfranchises persons from the privilege of those in the majority.  That is the focus of this article, but similar findings of marginalization are identifiable from socio-economic status, gender and religion.  This is a challenging topic because it elicits a strong emotional reaction from those struck by the centering of bias and exclusion, which may seem new to them and less relevant.  It is also triggering to those that have personally experienced intentional or incidental disempowerment.  But this difficult work is critical to our future as a field and to the health of patients we serve. 

There are two major aspects of disparate outcomes for patients receiving rehabilitation services which influence one another.   First is the effect of otherizing a group of people such that their outcomes are not driven exclusively by best practices for their particular diagnoses.  The root of disparate outcomes is a disparate assessment/treatment of those marginalized.  Examples of racial and ethnic disparities in rehabilitation outcomes are well documented:     

  • A review of racial and ethnic health disparities, done through the department of Veterans Affairs, prefaced a report on this issue as “the most serious and shameful health care issue of our time.”1 
  • The data identifies reduced healthcare utilization and access for Hispanics in the United States.2 
  • There are poorer functional outcomes for American Indian/Alaskan Native Children receiving inpatient rehabilitation.3 
  • Black patients are less likely to receive analgesia for acute pain.4 
  • Black and Latinx adult patients were less likely to be discharged from acute care hospitals to rehabilitation centers as compared to white patients following significant brain injury.5
  • This hospital discharge bias for adults was also present for pediatric patients.6 

These racial and ethnic disparities in acute care and inpatient rehabilitation services are also present in outpatient therapy access with a further impact of English-language proficiency7 and reliance on public insurance8 as augmenters of this reality.  Second, a significant factor of racial and ethnic health disparities is the lack of diversity in the rehabilitation work environment. Black and Latinx physicians are even more under-represented in academic medicine at all ranks and in all specialties in 2016 than 1990.9  That analysis included Physical Medicine and Rehabilitation.  The data is equally grim for rehabilitation-related allied health professionals in physical therapy 10, occupational therapy11, and speech-language pathology.12  Thus the profound lack of diversity in physical medicine treatment staff is not in alignment with the natural occurrence of racial and ethnic groups in the larger population.  That lack of representation is not only ethically troubling, it can cause financial and operational challenges for clinical practices  Healthcare disparities not only harm a significant number of patients, they are also a barrier to optimal metrics in performance-based reimbursement models for consultants, inpatient providers and outpatient providers across all patient age groups.  It is imperative to eliminate a reality inferred by the previously cited data that Physiatric outcomes are determined by the race/ethnicity of the patient.

Relevance to Clinical Practice

The need for equitable racial and ethnic outcomes for patients under the rehabilitation umbrella is crucial to a physiatric practice.  Change requires approaches that move from micro to macro:  targeting individual behavior, institutional factors, and systemic challenges.  Schematically, this is represented in Figure 1. 

Figure 1:  Resetting the Clock of Racial and Cultural Disparities

Disparities-Submission-KN-Clock-1Download

Legend:  The green arrow represents the evolution of societal thought.  It advances the clock towards the future as mores and norms evolve (clockwise rotation).  The red arrow represents resistance to change.  This is the force opposing modification created by the inertia of accepted or typical convention or societal order.  This slows or retards the advancement toward a new normal (counter-clockwise rotation).  The gears inside of the clock are the components that make the clock function.  They are factors that contribute to worsening or amelioration of the disparities. (Created May 2020, A. Kenyatta Parks & Maurice Sholas)

Starting at the most granular level, individual clinicians have to be aware of their biases and practice culturally competent care.  It will inform the overall quality with which patients are managed, and serves as a proxy for the competence of a provider.  At a larger level, those individual physicians and providers are part of a community.  Communities that are diverse and containing equity-oriented members matter.  Data shows that more racially diverse staff have better financial outcomes.13 Racially diverse treatment teams also have a more positive impact on patient trust and clinical outcomes.14 And, patients experiencing racism in a health care setting “…had a 2-3 times the odds of reporting reduced trust in healthcare systems and professionals, lower satisfaction with health services and perceived quality of care, and compromised communication and relationships with care providers.”15 These factors underscore the impact of the individual provider, and the community of care, on the patient experience. 

Examples of institutional or structural bias can be reflected in more unexpected ways.  The location of a facility that is not easily accessible to those using public transportation represents structural bias that could preferentially affect marginalized populations in a negative way.  Another example is a when a care organization has an unstated preference for private insurance or limits the number of patients on public insurance accepted for services.  This phenomena was demonstrated clearly when offices of orthopedic surgeons were called with a fictitious patient having a meniscal tear.  Medicaid patients were more likely to be denied an appointment and waited longer for an appointment when it was granted.16 These decisions seem purely operational at first glance, but result in a marked reduction of access for marginalized racial and ethnic groups; specifically Black and Latinx patients who are less likely to have commercial insurance.17   

Structural factors also include the work environment for providers of color and how well they are recruited, retained and promoted.  Like the Americans with Disabilities Act of 1990 codified the aspirations of inclusion for the patients physiatrists treat in the United States, Title VII of the Civil Rights Act of 1964 codified federal rules against discrimination in the United States based on race, color religion, national origin, or sex.  However, this prohibition has been less effective against the microaggressions and biases that have a negative impact on physiatrists of color18 and secondarily on the patients said providers serve.  The Oakland Men’s Health Disparities Study showed that having a black doctor decreased the black-white gap in cardiovascular mortality by 19%.19 Similarly, having a Black Physiatrist has the potential to be a powerful counter to the disparities demonstrated in this review affecting black patients.  Culturally competent care matters when providing care for racially diverse patients.  For an improvement in racial health care disparities, work environments that are affirming and inclusive for traditionally under-represented minorities are a crucial.  Negative institutional factors must be addressed and mitigated with intentionality. 

On an even larger systemic level, there has been an increased focus on health disparities in professional organizations representing the diaspora of medical services.  These groups focused on patient outcomes as well as the physician experience within their organization.  The American Academy of Physical Medicine and Rehabilitation founded a diversity and inclusion task force in 2019.  This led to a strategic plan with a three-year arc.  The change was sparked by increasing demands of community affinity groups and in response to lagging minority membership.  The American Medical Association, the American Hospital Association and the American Association of Medical Colleges have all appointed a senior level leader titled: Chief Diversity Officer.  All of those organizations have a history of being exclusively the province of white males.  In 2008, the American Medical Association specifically and formally apologized to black doctors for a legacy of exclusion dating back to 1870.  It is unclear if these changes represent simply an agreement in principle that issues related to racial disparities are important.  Or, if these initiatives will translate into better recruitment and retention of racially and ethnically diverse physicians and administrators who are then a part of a process that produces tangible changes.  It is critical that these multi-racial professional groups work with long standing affinity groups, created in response to exclusion, specifically representing doctors from marginalized groups.

Finally, the changes from the micro to the macro level that improve diversity in clinical practice require modification of training programs and pathways.  There is a clear role for education along the full continuum of medical training and maintenance of continuing education.  Issues related to health care disparities are programmatically a part of physician professionalism.  Insertion of medical ethics and humanities into the formal process of medical education at the pre-medical school level, medical school curriculum, post graduate training years and in practice is a proposed way to make physicians better able to recognize injustice and health inequity in the system.20 They can then use their power and privilege to overcome and reverse those findings.20 

It is the responsibility of the individual physiatrists, the systems within which they work, and the professional organizations supporting the House of Medline, to address racial health disparities in a multifactorial way.  At the individual level the benefits of equitable health outcomes and the elimination of disparities is obvious.   At the institutional level, the benefit is with improved revenue stream and performance metrics.  At the systemic level, this makes the professional and clinical staff more consistent with the racial and ethnic make-up of the populations they serve.

Cutting Edge/Unique Concepts/Emerging Issues

Unconscious, and often snap, decisions that people make about others are called unconscious bias.  That implicit bias may not be intentional, but contributes to health disparities.21 They influence the response a physiatrist can have to a person, their medical complaint and their perceived compliance with treatment recommendations. The degree to which a person has implicit biases against a given group is measured via the Implicit Association Test (IAT).22 Two key criticisms of this approach is that IAT results are not always coupled with training on how to make durable changes to those biases in the individual, and naming a bias unconscious minimizes the responsibility a given person has to actively combat health disparities and bias.  

A more lasting approach to change is for individuals and organizations to partner with existing social justice and equity organizations to craft best practice opportunities for their circumstance.  In addition to national groups like the National Medical Association, National Hispanic Medical Association, and the Association of American Indian Physicians, rehabilitation practitioners can partner with local student, trainee and provider affinity groups.  That adds a diversity of voices and perspectives to the practice of medicine as individual practice requirements and institutional standards are created.  Organizations with larger societal equity focuses also have divisions dedicated to health equity.  The National Urban League, Unidos, and the Color of Change have active missions that aligns with decreasing racial and ethnic disparities.  In making change, physical medicine practitioners do not have to reinvent decades of validated interventions and approaches to equity.  Partnership is a path forward.

Gaps in Knowledge/Evidence Base

Tackling race/ethnic biases in a systematic way can be challenging.   Lisbeth et all in 2018 conducted a survey-based exploration of Latinx patient experience following strokes.23 They partnered with inpatient rehab facilities, skilled nursing facilities, home health agencies and outpatient rehabilitation providers.   Initially 80% of the community partners agreed to participate and return the questionnaire data.  Ultimately, only 12% did so. The reasons for this may be multifactorial, but the reticence to report a reality that is perceived as negative or shameful is a barrier to understanding and addressing the reality of racial health disparities. 

Making progress and decreasing racial and ethnic disparities requires intersectionality and application of similar steps taken to close the gender gap in rehabilitation medicine.  It necessitates that the burden of change not be exclusively laid on those affected.  As providers that care for adults and children with physical disabilities, we are trained to advocate for this group of marginalized persons.   That advocacy must also be applied to deconstructing barriers to equitable health outcomes for those additionally marginalized by race and ethnicity.  That change requires a courage that persists in spite of the many factors that resist it, and a consistency that overcomes our history.

References:

  1. Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, and Waldrip K.  Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration:  An Evidence Review and Map.  Am J Public Health.  2018 March. 108(3): e1-e11. 
  2. Flores L, Verduzco-Gutierrez M, Molinares D, and Silver J.  Disparities in Health Care for Hispanic Patients in Physical Medicine and Rehabilitation in the United States:  A Narrative Review.  Am J Phys Med Rehabil.  2020 April.  99(4):  338-347. 
  3. Fuentes M, Bjornson, K, Christensen A, Harmon R, and Akpon S.  Disparities in Functional Outcomes During Inpatient Rehabilitation Between American Indian/Alaskan Native and White Children.   J Healthcare for the Poor and Underserved. 2016 August. 27(3):  1080-1096.
  4. Lee P, LeSaux M, Siegel R, Goyal M, Chen C, Ma Y, and Meltzer A.  Racial and Ethnic Disparities in the Management of Acute Pain in US Emergency Departments:  Meta-Analysis and Systematic Review.  Am J Emerg Med.  2019 January.  37(9):  1770-1777. 
  5. Gorman E, Frangos S, DiMaggio C, Bukur M, Klein M, Pacher H, and Berry C.  Is Trauma Center Designation Associated with Disparities in Discharge to Rehabilitation Centers Among Elderly Patients with Traumatic Brain Injury?  Am J Surg.  2020 January. 219(4):  587-591.
  6. Shah A, Zuberi M, Cornwell E, Williams M, Manicone P, Kane T, Sandler A, and Petrosyan M.  Gaps in Access to Comprehensive Rehabilitation Following Traumatic Injusries in Children:  A Nationwide Examination.  J Ped Surg.  2019 January.  54(11):  2369-2374. 
  7. Moore M, Jimenez N, Rowhani-Rahbar A, Willis M, Baron K, Giordano J, Crawley D, Rivara F, Jaffe K, and Ebel B.  Availibility of Outpatient Rehabilitation Services and Barriers to Care for Vulnerable Populations after Pediatric Traumatic Brain Injury.  Am J Phys Med Rehabil.  2016 March.  95(3):  204-213.
  8. Fuentes M, Thompson L, Quistberg D, Haaland W, Rhodes K, Karlin D, Kerfeld C, Apkon S, Rowhani-Rahbar A, and Rivara F.  Auditing Access to Outpatient Rehabilitation Services for Children with Traumatic Brain Injury and Public Insurance in Washington State.  Arch Phys Med Rehabil.  2017 January. 98(9):  1763-1770.
  9. Lett LA, Orji WU, Sebro R.  Declining Racial and Ethnic Representation in Clinical Academic Medicine:  A Longitudinal Study of 16 US Medical Specialties.  PLoS One.  2018.  13(11): e0207274. 
  10. Data USA. Physical Therapists.  https://datausa.io/profile/soc/physical-therapists.  Accessed May 21, 2020.
  11. Data USA. Occupational Therapists. https://datausa.io/profile/soc/occupational-therapists  Accessed May 21, 2020.
  12. Data USA. Speech Language Pathologists.  https://datausa.io/profile/soc/speechlanguage-pathologists.  Accessed May 21, 2020.
  13. Hunt V, Layton D, Prince S.  Why Diversity Matters?  McKinsey and Company.  Publish Date:  January 2015.  Web Link Reference 9
  14. Sederstrom N, Sholas M, Haredman R, Nauetz S, and Wu J.  The Color of Medicine:  Confronting the Problem of Racism in Clinical Settings.  14th Annual International Conference of Clinical Ethics Consultation.  Presentation.  Oxford, UK.  June 2018. 
  15. Ben J, Cormack D, Harris R, and Paradies Y.  Racism and Health Service Utilisation:  A Systematic Review and Meta-Analysis.  PLoS One.  2017 December.  12(12): e0189900. 
  16. Wiznia DH, Nwachuku E, Roth A, Kim C, Save A, Anandasivam NS, Medvecky M, Pelker R.  The Influence of Medical Insurance on Patient Access to Orthopedic Surgery Sports Medicine Appointments Under the Affordable Care Act.  Orthop J Sports Med.  2017.  5(7):2325967117714140.  DOI: 10.11177/2325967117714140 2325967117714140
  17. Sohn H.  Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage Over the Life Course.  Popul Res Policy Rev. 2017.  36(2): 181-201
  18. Overland, Zumsteg, Lindo, Sholas, Montenegro, and Campelia.  Microaggressions in Clinical Training and Practice (Ethical and Legal Topic, Editor – Mukherjee).  J Phys Med Rehabil.  2019 September. 11:1004-1012. 
  19. Alsan M, Garrick O, and Granziani.  Does Diversity Matter for Health? Experimental Evidence from Oakland.  American Economic Review.  2019. 109(12):  4071-4111. 
  20. Doukas D, Kirch D, Briham T, Barzansky B, Wear S, Carrese J, Fins J, and Lederer S.  Transforming Educational Accountability in Medical Ethics and Humanities Education Towards Professionalism.  Acad Med.  2015 June.  90(6):  738-745
  21. Zestcott C, Blair IV S, Examining the Presence, Consequences and Reduction of Implicit Bias in Health Care:  A Narrative Review.  Group Processes & Intergroup Relations.  2016. 19(4):  528-542.
  22. Greenwald A, McGhee D, and Schwartz J.  Measuring individual Differences in Implicit Cognition:  The Implicit Associations Test.  J Pers Soc Psychol.  1998 June.  74(6):  1464-1480. 
  23. Lisbeth L, Horn S, Ifejika N, Sais E, Fuentes M, Jiang X, Case E, and Morgenstern.  The Difficulty of Studying Race-Ethnic Stroke Rehabilitation Disparities in a Community.  Top Stroke Rehabil.  2018 September.  25(6):  393-396.