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Letters and Responses |
 | To the editor |
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According to the article, the minority population of the United States has increased from 24.4% to 30.9% from 1990 to 2000. The authors then state, "Despite this increased diversity in the US population, members of minority groups remain underrepresented in the profession of physical therapy." The next fact stated is that "only 12.6% of physical therapists are members of minority groups." My first question is, how does one achieve "membership" in these groups? As an Irish-German descendant, I do not have "membership" in any group, nor do I actively seek preferential treatment of others who would qualify to be in my group. I self-identify as an American male. To identify race or ethnic origin is problematic, as this article inadvertently illustrates. Why not strive for admission questionnaires that are blind to race? I am in full agreement that a person should be judged on the content of his or her character and not on the color of his or her skin, as Martin Luther King, Jr, proclaimed. Why then, do we need to know the applicant’s race or the color of the applicant’s skin before we even meet the person? The people calling for affirmative action and quotas are not seeking justice, but power. They want the power to tell employers and universities who they must accept. Forget about competence, test scores, and qualifications.
The authors refer to a report published by the Institute of Medicine (IOM), which draws the conclusion: "Racial concordance of patient and provider is associated with greater patient participation in care processes, higher patient satisfaction, and greater adherence to treatment."1(p186) The implication is that if your doctor does not share your skin color, you are less likely to adhere to the prescribed treatment. Mentioned in passing in the article as another cause of "ethnic disparities in health care" is patient mistrust or refusal. The implication here is that it cannot be helped if a patient is racist or biased against his or her provider and does not follow the prescribed treatment. This is a case of the tail wagging the dog. Instead of addressing the patient’s ignorance, the conclusion from the IOM is that the patient just didn’t have the "right-colored" health provider.
Affirmative action is an exclusive game to play, to be sure. If you are not darkskinned, you have no stake in the game. How vociferously have you heard anyone call for affirmative action for Asians or Pacific Islanders? They are an even larger minority than Latinos or blacks.2–4 And if diversity is the goal, why aren’t men classed as minorities in physical therapy program admission offices? In 2004, men represented only 32.2% of physical therapists, and women represented 67.8%.5 If this isn’t disparity, I don’t know what is. According to the authors’ logic, there must be institutional discrimination against men because they are underrepresented in the profession. The US Census Bureau of 2000 reported that there is almost (96.3%) a 1:1 ratio of men to women in the United States.6 Where are the articles and outcry from the IOM? Where is the study that investigates whether gender differences between provider and patient cause health care disparities?
And now the answer to why the work force does not always resemble the population. Disparity does not necessarily equal racism. Walter Williams (nationally syndicated columnist and, yes, black) astutely fleshes out this argument: "What else, but racism, can explain how blacks, who are 13% of the population, are 66% of professional football players and 80% of basketball players?"7 He suggests tonguein-cheek that this is racism against white players. He continues,
Everybody knows that blacks have a higher mortality rate than Chinese, Japanese, or Filipinos. This can only be chalked up to some mysterious Far Eastern form of racism, particularly when coupled with the fact that Asians receive less prenatal care than whites. Another disparity is seen in the fact that the proportion of Asian American students who score over 700 on the math portion of the SAT is double the number of whites.7
Williams’ point is that if we microscopically analyze every profession, test score, mortality rate, income, and so on, we will find differences, but these differences are not due to racism.
Cultural differences are evident in many fields of study. Noted professor of economics and civil rights author Thomas Sowell cites several examples: "Hispanic PhDs outnumber Asian PhDs in the United States three-to-one in history, but the Asians outnumber the Hispanics by ten-to-one in chemistry. Female PhDs are in quantitatively based fields only half as frequently as male PhDs."8 Following the logic of the article by Haskins and Kirk-Sanchez, we need more white, black, and Eskimo PhDs in chemistry because the Asians have a near monopoly. I say this facetiously, but this is the argument being made in the field of physical therapy for the "recruitment and retention" of more minorities.
I believe the answer is clear regarding diversity in the physical therapy profession. If the field of physical therapy wants to raise its standards, physical therapy education programs should seek applicants who have the proper academic and clinical skills needed to be successful. Filling a class or even graduating students from a program to fulfill a color-coded quota is unconscionable. Some will praise the institution as a bastion of diversity, but everyone knows the game, and the façade that the institution puts up cannot sustain itself.
Footnotes
To view this content online, visit www.ptjournal.org
References
The first premise of our study was that minority groups are underrepresented in physical therapy. Sorrell does not question the data from the US Census or the data from the American Physical Therapy Association (APTA), but asks, "...how does one achieve ‘membership’ in these [minority] groups?" The federal government defines minority groups, as do the Association of American Medical Colleges and APTA. The common thread in their definitions seems to be that minorities are (1) underrepresented and (2) historically discriminated against by society. We wish we could say that there is no bias and no discrimination in our professional association or our profession, but both popular opinion and substantial evidence show that society’s ills are mirrored in our discipline.1–9
Sorrell notes that men are underrepresented in physical therapy and asks, "...why aren’t men classed as minorities?" The answer is that men, particularly white men, have not historically been victims of societal discrimination in the United States. In fact, some would say that white men have benefited the most from affirmative action. According to Pulitzer Prize-winning columnist, Leonard Pitts,10
White men are the biggest beneficiaries of affirmative action this country has ever seen....If affirmative action is defined as giving someone an extra boost based on race, it’s hard to see how any one can argue the point. Slots for academic admission, for employment and promotion, for bank loans and for public office have routinely been set aside for white men. This has always been the nation’s custom. Until the 1960s, it was also the nation’s law.
Our second premise was that the under-representation of minority physical therapists is a bad thing because it affects patient care for members of minority groups. In support of this premise, we cited the Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,11 which was commissioned by the US Congress in 1999 and describes evidence of racial and ethnic disparities in health care across a wide range of disease areas, clinical services, and clinical settings. Sorrell ignores the important issue of racial and ethnic disparities in health care and instead criticizes the IOM for not examining "institutional discrimination against men."
Despite its politically motivated start, the IOM report is a compelling document. The IOM study was conducted under the auspices of the Governing Board of the National Research Council. The 15 members of the study committee were chosen for their expertise and varying perspectives. The members included the special advisor to the American College of Physicians, the director for nursing research at Johns Hopkins University, a professor of law from Georgetown University, a senior research scientist from the Harvard School of Public Health, and a professor of health economics from Harvard Medical School. The report (738 pages in length, with 474 references) was reviewed by 11 scholars chosen by the National Research Council Report Review Committee for their diverse perspectives and technical expertise and was overseen by the editor of Annals of Internal Medicine and by a professor of pharmaceutical and therapeutic research from Columbia University. In our article, we abbreviated the IOM study committee’s extensive findings to only a few sentences that summarize some of their conclusions and recommendations.
The IOM study committee found that even when controlling for education, socioeconomic status, and access to health care, disparities according to race and ethnicity still exist. Many sources contribute to these disparities, including health care provider prejudice or bias and patient mistrust and refusal. Sorrell equates "patient mistrust or refusal" with "patient ignorance." The chapter in the IOM report that deals with health care provider prejudice or bias and patient mistrust and refusal has 28 citations and an extensive and balanced discussion of the experimental evidence.11 Again, the scope of our article did not permit us to more fully engage in a discussion of all of the possible influences of mistrust and refusal that were examined in the report, nor did it allow us to discuss the historical roots of that distrust (eg, the Tuskegee Syphilis Study,12 the Jewish Chronic Disease Hospital Study,13 and the Willowbrook Study14).
The third premise motivating our study was that educators should seek ways to increase the number of minority group members in the profession. Sorrell focused on affirmative action and on equating affirmative action with "quotas." Senora Simpson, a physical therapist and a prominent member of APTA, has written of affirmative action, "Critics hear the term and leap to the conclusion that one is suggesting quotas and diminution of standards."3(p164) That certainly is the case here, as nowhere in our article do we propose the use of quotas, nor do we suggest that educators "forget about competence, test scores, and qualifications" as Sorrell asserts. Instead, we have conducted research to identify strategies that can be used to supplement regular admissions procedures to enrich the applicant pool without resorting to the use of illegal and indefensible quotas. This approach is totally in accord with the following House of Delegates position15:
The American Physical Therapy Association (APTA) is committed to serving the needs of all people who require physical therapy and to meeting the needs of all its members. As noted in its policy, Non-Discrimination, APTA "prohibits preferential or adverse discrimination on the basis of race, creed, color, sex, gender, age, national or ethnic origin, sexual orientation, disability or health status in all areas.":The Association’s stand against "preferential or adverse discrimination" does not negate the need for APTA to act affirmatively for certain classes of people, identified by race, color, sex, gender, national or ethic origin, or disability or health status. APTA supports the planning and implementation of comprehensive Affirmative Action programs.
Sorrell asks, "Why not strive for admission questionnaires that are blind to race?" His assumption is that the admission process is fair to all. Most educators would disagree with this assumption. The "brightest" student (ie, the student with the highest grade point average) is not always a good clinician, and a student who has success on internships may not always be strong enough intellectually to pass the licensure examination. Because grades alone may not be enough to assess a student’s academic ability, educators gather more information about applicants through standardized tests (which have been shown to be biased against members of minority groups)16–19 and interviews (which carry the potential for bias). Thus, there is no "blind" admissions process, but even if there were one, we would be doing our patients a disservice if that process resulted in a profession that lacked diversity serving an increasingly diverse population.
We do agree with Sorrell that the underrepresentation of minorities in physical therapy is not due solely to racism and discrimination. The shortage of role models in the profession certainly contributes to discouraging members of minority groups from selecting physical therapy as a profession, as do many other factors such as lack of information about the profession, inadequate counseling, lack of information about financial aid, and inadequate educational preparation.20 That is entirely consistent with what we found in our study: the programs with the higher proportion of minority students utilized minority faculty members in recruitment; provided mentors; provided information about the profession through brochures, flyers, and pamphlets; conducted visits to elementary schools and minority institutions; participated in health fairs; disseminated financial aid information; and provided preprofessional enrichment courses. According to the Centers for Disease Control and Prevention, "Compelling evidence that race and ethnicity correlate with persistent, and often increasing, health disparities among US populations demands national attention... the future health of America as a whole will be influenced substantially by improving the health of these racial and ethnic minorities."21
haskins{at}fiu.edu Department of Physical Therapy, Florida International University UP Campus, HLS 339 Miami, FL 33199
Department of Physical Therapy, Miller School of Medicine, University of Miami, Miami, Fla
References
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