Attitudes, Beliefs, And Biases That Contribute To The Marginalization Of People With Pain With Alicia Emerson, PT, DPT, MS, OCS, FAAOMPT

Welcome back to the Healing Pain Podcast with Alicia Emerson, PT, DPT, MS, OCS, FAAOMPT

While the world has made great progress in business and technology, healthcare is still lagging behind other major sectors. There are a lot of factors that cause stigma in this space, and the marginalization of people with pain is still rampant. In this episode, Alicia Emerson, PT, DPT, MS, OCS, FAAOMPT of High Point University joins Dr. Joe Tatta to discuss the attitudes, beliefs, and biases that contribute to the shortcomings of the healthcare industry. She explains the impact of sociopolitical factors on the perceptions of healthcare providers that make it harder for the vulnerable to get access to appropriate care. Dr. Emerson also presents the best ways to overcome these barriers and create a more inclusive and supportive environment for people with pain. Whether you are a healthcare provider, a caregiver, or someone who lives with pain, this episode offers valuable insights and practical tips for navigating the complex landscape of pain management.

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Attitudes, Beliefs, And Biases That Contribute To The Marginalization Of People With Pain With Alicia Emerson, PT, DPT, MS, OCS, FAAOMPT

In this episode, we’re discussing how a healthcare provider’s perceptions of sociopolitical factors can have an influence on vulnerable and marginalized people with pain. My guest is Dr. Alicia Emerson. Dr. Emerson is an assistant professor and Director of Clinical Practice in the Department of Physical Therapy at High Point University in North Carolina.

She is also the Director of High Point University’s Pro Bono Physical Therapy Clinic. She is currently completing her PhD studies. Her research interests include understanding the sociopolitical influences on chronic musculoskeletal pain and outcomes and discerning the functional implications of pain processing for people with chronic musculoskeletal pain.

We’ll discuss some of the clinical conversations that happen in the world of pain management with regard to working with vulnerable populations or people who are vulnerable. We’ll discuss provider attitudes, beliefs, and biases that may contribute to the marginalization of people with pain or impede the process of effective pain management. Without further ado, let’s begin and let’s meet Dr. Alicia Emerson.

Alicia, welcome to this episode of the show.

Joe, thanks so much for having me. I’m excited to be here.

Thank you for accepting the invitation. I was doing some research online and came across some of your work. I know it’s part of your PhD work, which we’ll talk about in the episode, but this has also become a passion of yours. You’re interested in raising awareness around these topics. Everyone is excited to hear your research, thoughts, and opinions on things.

The topic of politics and sociopolitical issues around pain, we’re talking about them more and more in professional circles because we’re becoming aware of that. These political determinants have an influence on things. What motivated you to start looking into this area? There’s not a whole bunch of research in this area.

Part of it started because I was a clinician for fifteen years. I moved from this itty-bitty town in Central Illinois to Chicago. I worked primarily on the South and West sides of the city in socioeconomically deprived neighborhoods. The patients I saw were very diverse. I saw the CEOs and people that were unsheltered. I saw people that were in prison or recently incarcerated. I saw the police officers that may have been involved in that.

I saw stay-at-home moms, manual laborers, white-collar, professors, and students. I saw the whole gamut of diversity just on socioeconomic status. That also meant I saw a huge diversity of patients who had access to healthcare based on their insurance. I saw people that had no insurance all the way up to the fanciest of PPOs that were treated like royalty once they came into the healthcare system. It was interesting to me as I learned about managing complex conditions and particularly those with chronic pain.

HPP 304 | Marginalization Of People
There is a huge diversity of patients who had access to healthcare based on their insurance. There are people who have the fanciest of PPOs and were treated like royalty once they came into the healthcare system, while some has no insurance at all.


I was struggling at the moment like, “What am I missing when I’m talking to this patient?” I’m not understanding either their experience. I don’t know if you remember the Waddell Sign from way back when, but you almost capture the patient faking it in these chronic pain conditions. I’m like, “It’s not matching what I’m seeing.” I was trying to put piece all this together. At the same time, I was practicing when the Affordable Care Act was passed.

In 2011, as steam was gaining, we had a ton of patients coming into our healthcare system, particularly at UI Health, which was the largest provider of Medicaid in the State. All of a sudden, I’m treating patients that hadn’t seen anybody for 20 or 30 years. The complexity of their cases and the number of unmanaged comorbidities they had ongoing there was a struggle to overcome that component before you could even get to managing the pain.

I’ve always toggled back and forth as the clinician like, “What’s going on at the moment, and then what’s driving this patient here.” Jeffrey Rose had asked and challenged physicians years ago to understand, “Why is this patient sick? Why is this population sick?” That has been my driving focus now as I’ve moved into academia.

The start of this whole PhD process was my opening the pro bono clinic here at High Point University. It’s opened 40 hours per week, so we think it’s the only one in the nation open 40 hours per week. We have one and a half full-time clinicians and students. It has been this journey of recognizing my difficulty in being successful as a clinician, and then seeing all those factors at play throughout the years.

Do you have any sense of how we might be educating new professionals or maybe the professionals out there to start to think about these types of factors and issues? You’re talking about big issues that exist. Private practitioners are acutely aware of what insurance will provide enough visits to maybe work with someone who has chronic pain versus those that don’t.

Oftentimes, these conditions are squeezed into almost a biomedical approach where you get eight visits and see what you can do. It’s like this person has fibromyalgia, and they have other comorbidities. That doesn’t necessarily work. You’re starting to get down into the nitty-gritty and say in some way that our insurance system may not be set up for certain people with certain conditions.

It’s not just that. Our insurance system isn’t set up well, but our educational system isn’t set up well. When I came to High Point University, I was trying to do what you were saying. I had taken these entry-level students. I need them to be facilitating some of the care in the pro bono clinic, and they don’t have any pain science knowledge. They don’t have a background in these social determinants of health. What I did was create a three-hour credit course on pain science.

One of my colleagues, Cory Alcon asked, “How many other programs have one of that?” We did a survey and there are not very many DPT programs that have a standalone three-credit class. Foundationally, we’re lagging at that component of it. Even if we’re trying to talk about pain, what I struggle with the students is most of them are used to having a biomedical condition.

I would say 90% of students come in because they had some kind of injury. That injury showed up on an MRI, which usually resulted in surgery like an ACL tear. They are into sports or they are athletes. It’s something we can have a common conversation about. You struggle with what happens to the patient that doesn’t have imaging. Now they have an invisible condition, particularly if we’re looking through a biomedical lens. What is capturing their story?

I had done some research on NEOA. When I was looking at it, patients in their 30s would have these severe NEOA findings that we weren’t expecting. They might have known NEOA findings, and they would have terrible pain. The level of pain was not reflective of what the imaging looked like, but that almost did them a disservice because then they were exaggerating and faking because the imaging didn’t support what they said.

We’ve got an invisible condition that is being experienced almost exclusively or more at risk by those that are invisible or at risk for being invisible in our society. What we’re also missing is a foundational understanding of these social determinants of health and how marginalization, vulnerability, and things like that contribute to one’s condition. I think we’re not doing a good job right now, foundationally. We have to capture that post professionally as well to catch up on what wasn’t taught when I was even in school.

It is interesting to think about how information is traveling so fast nowadays. We have to be very flexible as practitioners. Instead of looking at the rigid scope and maybe even a rigid education system, those things have to be flexible and change probably on a yearly basis. We can’t wait necessarily for CAPD to change requirements and to send the email out to everyone. That should happen and we need that but for us to serve and if we want to, one of the missions of the APTA is to improve the human experience. That means working with populations, which a lot of your work points to. We need to act faster.

We need to act faster and not wait. If you look at CAPD, it’s something ridiculous that we look at pain, and yet pain is the number one reason somebody is going to see you in the outpatient orthopedic world. There’s a disconnect between what we’re requiring at a huge administrative level. There’s that system issue with what we’re encountering with the individuals.

We have to be more agile and recognize that because of what you may have seen in physical therapy either as a student or a clinician. Maybe they didn’t do that before, but it doesn’t mean we don’t start doing it now. You look at the conversation about capturing blood pressure and vitals. One in five or four PTs does that. Why are we not all doing that?

The research points out that we often don’t think it’s part of our scope of practice, and yet if you look at the risk factors for developing pain, cardiovascular conditions are going to be part of those biological factors that are driving experiencing pain either now or later. Practicing at the top of our license does mean we need to start thinking about all of these factors.

Practicing at the top of your scope or the top of your license is a message. You can see my professional bio now. I talk about it in my bio. That should be the message for our profession. We have a very exercise in the manual therapy-oriented profession. That’s wonderful. We need that. We should not lose that. However, our minds should open like a cavern and realize that as doctor-trained licensed healthcare professionals, we’re adaptable. We can adapt.

What’s the number one reason people want to come in? It’s not just that they were injured, but they enjoyed the relationship they established with the physical therapist. The PT incoming students I interview say, “It’s that relationship. No other healthcare profession gets to have that relationship.” You have to have a relationship not just with the people you want to have a relationship with, or that look like you, or that have been through that. You have to have a relationship with everyone. How do we build on communication? How do we build on recognizing that that’s an important skill?

Doctoral-trained and licensed healthcare professionals must have a relationship with everyone. They must not only focus on who they prefer to have a relationship with. Click To Tweet

Talking about people who may or may not look like you or come from similar backgrounds and things like that. A lot of the work that your research starts to point to and bring to light discusses things like marginalized groups that are marginalized in pain care, and groups that may be more vulnerable or have a lack of access to pain care. Those words are sometimes thrown around. Maybe give us your definition of vulnerability to chronic pain, and the marginalization in regard to chronic pain.

When I was doing my PhD work, I grounded vulnerability in the biopsychosocial model. If you look at vulnerability, we can define that as having either these conditions or living in these conditions that put us at risk for harm or resilience to recovery from that harm. That could be a biomedical condition, cardiovascular disease, a disability, or something along that from the psychological part or the mental health of it.

It could be a mental health concern that can make you more at risk for vulnerability, and then we have these social concerns. In the nursing profession, they often talk about those social determinants of health and where you are on the socioeconomic spectrum. If you have less or are in a deprived state, you’re at a bigger risk for vulnerability. You can only take so many financial hits before you’re going to be in trouble.

It’s helpful to remember that vulnerability can be identified for us in the biopsychosocial model. More importantly, if we know we have a vulnerability, there’s an ethical mandate that we need to explore those factors related to that vulnerability. If there’s a way for us as healthcare providers to mitigate or alleviate some of those factors, then we have a role in developing that.

That’s how I set up vulnerability. Marginalization is when a person, a population, or a group of people is pushed to the side. Typically, we think of that in a sociopolitical process. Do you have a voice in the vote? Are you supported by policies? What I’m saying is that we tend to marginalize, not always, but we can marginalize particularly when we’re working with patients that have chronic pain at that moment and in that visit.

Are you talking over your patient? Are you not listening to them? Do you have unmet expectations? Do you jump right into problem-solving, which we tend to do as PTs? If we’re not listening to them, then their voice is being pushed to the side, and then they’re not part of that shared decision-making model that we say we want to be a part of.

I’m saying that we are at risk, particularly for patients that have this invisible disease of chronic pain or even if you want to call it fibromyalgia and lump that in there, chronic low back pain, or whatever it is. We get frustrated. We can stigmatize those diagnoses, and then we are at risk of pushing them to the side, not letting them have a voice, and then they’re not actively participating as much in that visit. That’s where we get into trouble.

That’s interesting. I haven’t heard anyone frame it like that. I’ve done a lot of interviews and most of it was about pain. What you’re saying is that even though a provider may feel like they are patient-centered or person-centered, if you asked 100 PTs in a room, “Do you feel like you provide person-centered care?” Most people would raise their hands.

“Do you think you have a good therapeutic alliance with patients?” Most people would raise their hands. If you asked people, “Who has a below-average therapeutic alliance?” Most people are not going to raise their hands. You’re saying that you can effectively marginalize someone by not allowing them to have a voice and a choice in the therapeutic process.

I’ll skip ahead to what I did a little bit in my PhD. I did ask some of the providers in the State of North Carolina, “Have you ever had difficulty establishing a conversation that optimizes your care?” About one in three did admit to that. It’s great that they’re being vulnerable and willing to acknowledge that. There’s an opportunity for us to acknowledge the difficulty and then figure out what is that difficulty in that conversation. Is it that we maybe are blaming the patient in that component of it?

You mentioned professionals. It’s not just PTs, but a lot of healthcare professionals do this. It’s this reflex to jump in, problem-solve, figure it out, and fix things. Could you give us another example maybe of how a professional marginalizes a patient? This is subconscious.

There are two things. One, I want to highlight Kenneth Craig. If you haven’t worked with him before, he’s out of Canada. He has the social communication model of pain. He’s highlighting these neurophysiological processes that are ongoing in pain. If you communicate with a provider or caregiver, and that is a positive experience, you can tamper down and get those inhibitory processes going. If you have a negative interaction with that healthcare provider, that can negatively influence the patient’s experience and pain, which would make sense.

HPP 304 | Marginalization Of People
If you get a positive experience when communicating with a healthcare provider or caregiver, you can tamper down and get those inhibitory processes going.


If you and I were arguing now, I would get very stressed and frustrated. We would have these neurophysiological responses. As patients, we don’t get to express that necessarily back to the provider. It doesn’t mean we’re not experiencing it internally. We have to be careful in these conversations that we aren’t having an iatrogenic effect on that patient with their pain. Iatrogenic, typically you think that we’ve caused the problem, but it can also be an exasperation of a current symptom.

That’s where I started my thinking. It was using that theoretical model of how our interactions can influence. It’s that component of it. A lot of it is implicit. There are a lot of research and systematic reviews that we ended up doing demonstrating measured implicit biases. Those are typically looked at from a race, ethnicity, and gender perspective.

We also had unmet expectations. We had some biases against the legitimacy of a case if they didn’t have medical imaging to support their condition. They had high pain severity reported, and demonstrated those non-verbal behaviors. All those things you’re trained to look for someone that’s faking it show up in case vignettes. They show up in the case chart reviews that were done in these things. A lot of it is not intentional, but it’s part of that culture and greening we have about what pain is, and then who is deserving of care for pain.

Also, what interventions were used? It’s interesting. I was on a podcast with Karen Litzy, who you may know. I was interviewed by Karen Litzy. She has a podcast called Healthy, Wealthy & Smart. I was there with my co-editor, Ginger Garner. We wrote a book called Integrative and Lifestyle Medicine. She posed a question to us and said, “As a physical therapist, we use exercise, but you’re now bringing integrative and lifestyle medicine in where you’re bringing in things like sleep and stress management, and identifying substance use, nutrition, social connection, and all those things.

How do you do all that if you’re also doing exercise?”

Consider for a moment that we should give patients choice. Even though we are extremely biased toward exercise and movement as a primary modality to manage pain, someone may want to start actually with sleep. They may want to start with nutrition or stress management, or a variety of things that we could educate and counsel around. Does that resonate with you? If you’re pushing exercise on someone, does that tend to marginalize them and in some way, disempower them from the therapeutic process? 

Yes. It most definitely resonates with me. Garrett Naze has done a lot of research, and he’s the one with me. He’s my full-time clinician in the pro bono clinic. He had come from a provider-extending model when he was doing his PhD. He was the one that introduced me to, “Let’s screen for stress. Let’s screen for sleep. Let’s screen for these things, and then let’s start the conversation for management there.” Often with our patients, we know that obesity is related to chronic pain.

What we want to do is get everyone to exercise so they lose weight. Can I get that exercise inoculates this against pain? It’s all great and I like my exercise.” However, our patients don’t always like to exercise. How do you build at that moment that therapeutic alliance? You are not telling them to go do this and that and the other to say, “What would be best for you now?” You’re giving them options.

We have a huge intake screening form, probably bigger than most, but it doesn’t mean that most clinicians aren’t looking at things like that. “Let’s talk to them about what you answered about what is the most problematic of that.” I sometimes find students and even some clinicians get uncomfortable with having those conversations. We’re not trying to be outside our scope of practice. If you can recognize how these factors all are at play, particularly in chronic pain, then it gives you the opportunity to have those conversations and then get referred on as necessary.

I always tell my students, “The patients that we’re seeing with chronic pain are like those patients that are athletic that you are super excited to treat with that one exercise. Don’t you look at those patients at their sleep and at their stress and what their water intake is? Why are we not looking at that with the patients that have pain? Don’t you look at that and treat them as well? Why do we treat patients with chronic pain any differently? I don’t understand that.

All humans and all conditions are layered. Tell us about your research. It’s a big part of your time over the last couple of years. Tell us what your research was about, your hypothesis, and some of your findings.

My hypothesis was, and I was curious, do we have sociopolitical and historical factors influencing our conversation when you’re chatting with a patient? That got driven because when I was in Illinois working with all those patients that were all of a sudden coming into the healthcare system, they were telling me about both their positive and negative interpersonal experiences. I then moved to North Carolina and there’s a difference.

We crossed a state, Illinois. The difference was North Carolina didn’t accept the expansion of Medicaid and still has not accepted the expansion of Medicaid. It’s one of several states in this region that did not. Now there’s a huge amount of patients that need to be seen all because of a decision made at a policy level. I’m like, “I’ve got a pro bono clinic. Wouldn’t you all like to come in and get some free physical therapy? One, let me survey what they want.” I was getting into community engagement and what that meant.

That’s important as we move forward, and I’ll talk about that later. First, we called all the English-speaking lines and that’s great, but recognizing that most patients that I would be trained to target probably did not speak just English. I went back and did those surveys in Spanish and Arabic. I intentionally picked those, given some of the rhetoric that was going on around that presidential election time and recognizing that.

It took me forever to get those surveys done because no one wanted to talk to me. They didn’t care how great this idea was. They’re like, “You’re a healthcare provider. I don’t want to talk to you.” I was curious as to why you didn’t want to talk to me. Once I was able to get to someone, they said, “Don’t you know in North Carolina, healthcare providers used to track documentation status.” I have no idea if that’s true or not, but that is what that community believes.

Until I was vetted by someone within the community that they trusted, I was never going to get anywhere. That’s where I was like, “Maybe patients are invisible to some of us healthcare providers because they never come into the system.” We don’t even know they’re out there. Why are they not out there? It’s because of all these things that had gone on both historically and contemporaneously at the same time. I was like, “That makes sense.” I went on and did some focus groups. We tried to combine those efforts.

Maybe patients are invisible to some of the healthcare providers because they never come into the system. Click To Tweet

There were some obstacles to care that were recognized. Often those were centered on health insurance. They recognize that healthcare is a business now. No matter how well-intentioned we are as providers to work outside those constraints of business, they still recognize it and we recognize it. They just wanted us to communicate as if they are human beings.

I still recall this one Spanish-speaking patient that we had. He was a car mechanic. He was like, “When you come in to see me, I write down everything you’re telling me. You tell me that this makes this sound, and it does this. I’m trying to diagnose what’s wrong with your car. When I go see a healthcare provider, they look at their paper, and they don’t even listen to me. They have these questions and go right through it.” He was able to articulate that difference where he wanted to be heard and seen essentially. That was the first half of what I had done.

This is true of many people who are marginalized in the healthcare system. Immigrants and new Americans are one group of people who recognize that their behaviors are being tracked. The queer community has been through that in the past with AIDS and with other things. Even some of that is still carried out now, where they don’t have trust in providers. They are scared to disclose their sexual identity and orientation. They’re scared to disclose their gender identity. Especially in the chronic pain population, those things are barriers that have to come down.

We have to recognize that those barriers have existed and are still ongoing. We have to make sure that we figure out how to address those. One of the ways I do it with the students is I have those community leaders that vetted me come back each summer and talk to the students before they go into the pro bono clinic. They talk about the constituents’ experiences and their perspectives on what’s going on. I’ve had the NAACP come in, and they might talk about housing and why neighborhoods are the way they are.

I have Guilford Green come in, which is an LGBTQ. They talk about gender rights. I have the Latino Family Foundation come in. It’s helpful for the community to be heard both in the clinic, but also at the educational level and start planning that awareness. I had to hear from the providers. If I’m going to have a conversation, I needed to get both sides. I did survey the physical therapist and the physical therapist assistant in the area. I’m curious, “Did you have trouble establishing the conversation?” Some of them did, and we did some follow-up focus groups.

There were difficulties encountered in that conversation, but what I found is that they would sometimes blame the patient. “The patient was the issue. They didn’t follow through on that recommendation. They didn’t come. They didn’t care. They weren’t interested.” The clinicians often talked about the burdens. It was almost like insurance. I used to think that chronic pain was the stigma, but now insurance is the stigma.

If that person came with Medicaid or Medicare, that associated burden or that administrative burden is a lot. It gets overwhelming. I don’t know if it’s burnout that might come with that, but as we get burned out, we start to stigmatize. As we stigmatize, we lose our ability to empathize. The extinction of empathy is stigma.

If we are stigmatizing, we can’t empathize. If we can’t empathize, we can’t establish that therapeutic alliance no matter how well-intentioned. There are implicit biases that you’re talking about before. They go beyond the attributes. They’re about what we’re doing and how we’re feeling about that too. What I thought interesting is almost all of the community members that I interviewed thought patients should have universal access to care.

The healthcare providers didn’t necessarily seem to think that access to physical therapy was a basic human right. It was interesting to see those at play. It’s an emerging theme that needs to be explored a little bit more. I heard a lot of dissonance in that conversation where they endorse empathy when I ask them on a survey. We don’t always hear empathy when we’re having focus group conversations. They endorse these aspects of what chronic pain is. It doesn’t always come across. Dissonance is the next step. You’re aware of your own dissonance and the disconnect, and how we manage that. That’s what I don’t know yet.

Most of your research is good qualitative research.

It’s all mixed methods. Two systematic reviews were quantitative. One was a meta-ethnography, which is a fancy word for a qualitative systematic review with a new theme.

Congratulations on doing mixed-method studies. I did one, and there is a lot of work as they’re both quantitative and qualitative that you have to account for and write up and include.

It is a lot, but when you think about it, that’s what we do all the time as a clinician. Don’t we capture data? We ask questions and capture data quantitatively and qualitatively. It felt natural for me when I got into academia to do that.

I agree. It feels natural for me too. Unfortunately, a lot of journals like quantitative studies only. They don’t warm up to the mixed methods. Especially in regard to bringing people’s voices in, you’re bringing in the voice of these marginalized groups and people who are vulnerable. You’re brought in the voice of the clinicians. You can’t do that in quantitative research as much or get rich data that you can gather from qualitative research in that case.

You only get part of the story and that’s our problem. Quantitative research is done on people that want to come. Why do you want to be a research subject? You probably haven’t had a negative experience in your population or history that would negate you from wanting to do that. You typically have a lot fewer comorbidities. By the nature of chronic pain, you probably are at risk for having a few other things going on. It works great for this.

You said two things I want to rewind and go back to, which are interesting. I’ll paraphrase this. You said something along the lines of some of the providers identifying that people were either non-compliant or non-adherent or weren’t motivated. I always find that interesting because when you think about the number of hurdles that people have to go through in our healthcare system to get to someone like a physical therapist, they’re motivated. It’s just that somehow, in that therapeutic exchange, something was glazed over or missed.

You bring up a good point, and there are two things I should say. I go back to candidacy. First, the patient has to feel that they are in a position where they need to seek out care. Particularly, when a population has had such a negative experience personally or historically. For them to come means that something must be bad. Otherwise, you’ve got that “They’re just plugging along” mentality. They’re there for a reason.

We didn’t define this quite yet, but when you think about the clinical conversation, we often define it as you the patient, and me the provider, trying to figure out what your problem is, and then me jumping in and giving you a solution or maybe hopefully, working a little bit more on that shared decision-making. I’ve defined that clinical conversation more under the umbrella of that process of care.

Think about how many times you’ve had a patient come into your clinic to say, “I have to be here because of insurance before I can do X, Y, and Z.” The doctor said, “Come on. It’s not going to do you any good, but we have to do this one thing before you can do your next surgery or injection or whatever they want.” How many times has the admin person treated you poorly, and so you’ve had this negative discriminatory experience before you even get there?

What we’re missing is that we’re stepping into the stream of that patient’s overall existence and experience. We’re only going to see them for this cross-sectional moment of the time. We’re making decisions and judgments very quickly based on this short amount of time we have with them. They’re bringing all of their experiences with them.

HPP 304 | Marginalization Of People
Healthcare providers forget to step into the stream of an individual’s overall existence and experience. They make decisions and judgments in the short amount of time they spend with patients.


We don’t recognize we’re bringing our experiences with us. That’s where those missed expectations and judgements beyond implicit biases we may have talked about before. That’s where the mismatch comes in. When we don’t have met expectations, then we have different perceptions of why someone is doing it. Isn’t that statement like, “You don’t perceive things the way they are. You perceive them the way you are.” That’s the component of it there.

The second piece is you said you surveyed practitioners, but were they all physical therapists?

They were physical therapists or physical therapist assistants in the State of North Carolina.

A lot of them reported that they don’t see physical therapy as a right.

That emerged more from the focus groups. We surveyed 348 or so respondents on that. About a third of those indicated that they had difficulty with that conversation. In my follow-up focus groups, I was curious as to what were some of those difficulties. It came down to insurance. “If you’re paying for it, then you’ve got skin in the game,” was one of the phrases I heard, and that you’d be more motivated to be involved.

If you compare to what the participants were saying that everyone should have access to care, I didn’t always hear that coming from the PTs and the PTAs. They were more focused on, “Did you pay for it? If you paid for it, then you can come in and then you might be more likely to do what you’re supposed to do.” It wasn’t necessarily that we should be reaching out to all the communities all the time. It wasn’t everybody, but that was a strong subset of conversations I ended up having.

Were you surprised to hear that finding?

Yes. The whole last chapter of the PhD, I wrote grumpily for a bit because I’m not understanding what it is. I was talking to David Baxter and Ram Christian, my supervisors. They’re like, “This dissonance is what’s important.” We’ve approached physical therapy as we want to give back, and we have this code of ethics about reaching out and providing pro bono care. That’s part of that code of ethics but there’s a component of it that I was surprised that we’re not all in that same way. It’s always good for me to recognize there’s more than one point of view too.

You’ve used the word dissonance. Some people may have a very good grasp of what that means, and some people may not. Can you explain to us what that means?

What I’m saying is you’re saying one thing. In the surveys, everyone was like, “I am endorsing that I’m empathetic and empathy is important.” I had five questions related to empathy and I asked them in 2 or 3 different ways. They all keep answering the same way on empathy but when we follow up on it, what happens in a survey is we answer in the way we think people want us to answer. When we’re having just a conversation, then more of it comes out. There’s a bit of a disconnect between what you’re saying and what you’re doing. That’s where I’m pulling out the dissonance there.

We answer surveys in the way we think people want us to answer them. But once we get into conversations, more of the truth comes out. Click To Tweet

I need to rewind this and think about this for a moment. I would imagine there’s a component because we’re talking about putting this in the context of politics. especially in the United States of America where people pay for their insurance. There are a lot of people who think, “We shouldn’t have universal healthcare. You should work and pay for it. If you don’t make enough money or can’t afford it, then figure out a way,” or something like that.

Is that where it’s coming from? There’s also an ableist tone in there a little bit that concerns me, especially since these are physical therapists talking like that. Ableism is another thing that I’m starting to raise awareness around, especially in the chronic pain space, the idea that someone should completely recover and return back to a full sport. I’m like, “That’s not going to be everyone’s reality.” People can participate in life in many different ways. We have to make room for that for people.

That’s interesting. I’ll have to ponder on the ableist because that hadn’t been on my radar yet. I appreciate that insight. Back to your insurance thing. Because I’d been asking around the time of the presidential election, I have a feeling that’s probably where some of that had been coming from. When I look at the patients that we are treating in the pro bono clinic, the majority of them are working. They may be working more than one job.

There’s also this disconnect typically in a healthcare setting. As a healthcare practitioner, you will have access to health insurance. You project that anyone that works should have access to health insurance. That’s just not the way of the world anymore. Even if you’re working, you don’t necessarily get insurance, and we forget that.

It’s doing a disservice and perpetuating a stereotype about the patients that don’t have insurance and who they are. I try to poke holes in that whenever I can. The majority of our patients are hardworking and diverse, but they need care. They want care. They’re no different than you and me. They happen to have been born maybe in a different place or at a different time. That’s out of their control.

I’m going to talk more about this too as my show evolves. One of the principles that we’re all embracing is that pain care is a fundamental human right. If pain care is a fundamental human right, then you may not necessarily have to have insurance, but you have to have access to care then. In the United States, the way we access care is typically through health insurance. Luckily, people like you have pro bono clinics. We need more of those and there’s not enough. They oftentimes exist in a university setting. Most PTs would say, “Pain care is a universal right,” but they’re not necessarily connecting that the insurance is probably a piece of that process to have it be a right.

I would agree with you. Even if you have insurance, that doesn’t mean you have physical therapy. When I first moved to North Carolina, even if you had Medicaid, you only got one visit of physical therapy no matter what your diagnosis was for the whole year. It is not just a matter of insurance. It’s a matter of what insurance and how much physical therapy you’re getting.

You’re going to exhaust those benefits right away and then what happens? We get frustrated, but we don’t necessarily deal with it if you’re the provider because then the patient moves on, and they’re out of the clinic. On the other hand, if you are the person that has that limited insurance, you’ve got a different perspective on how insurance is sometimes getting you substandard care.

If you have limited insurance, you've got a different perspective of how insurance is sometimes getting you substandard care. Click To Tweet

I can go on a tangent about this, but we preach interprofessional care for everything nowadays. Everything has to be interprofessional. I’m like, “Our healthcare system and our insurance system are not set up for interprofessional care.” You can keep preaching that. You can keep sticking to websites. You can keep putting it in your peer-reviewed paper and it sounds great, but it’s not a reality for many people in the United States of America for numerous reasons. Everything from providing access to time and finances to living in parts of the country where there are no PTs, no mental health providers, or no physicians.

I was having that conversation with some of my colleagues. It’s like, “I have insurance. I am trying to get a regular annual checkup in, and it’s a five-month wait. What if I had a problem and now I have to wait for another?” I have that and I can deal with it because I’m healthy. The patient that I’m trying to see, and often the patients with chronic pain talk about disjointed care because they get passed from one provider to the next. They keep telling their story and get pushed back. We’re creating chronicity. If we would’ve dealt with it in the first place, we wouldn’t be spending $600 billion a year in 2012 on this condition. This is now a public health problem.

We’re perpetuating trauma is what we’re doing. It’s a great example. If you and I have a difficult time negotiating the healthcare system, what is it like for people with chronic health conditions? As we start to wrap up, I know your research goes a lot deeper on other topics, but a lot of your work will help inform what educators and health professional programs do like DPT educators. What are some of your recommendations on how we can take your research and not wait for CAPD to make a recommendation and start to act a lot sooner and be more flexible?

I would love to think that we’re flexible working in academia but that’s not always. First of all, we need a firm pain science foundation. If you don’t understand the neurophysiological processes and those social determinants of health risk factors, you’re never going to understand what to do. In the survey that we had just done, faculty are more confident that their students are prepared for acute or sub-acute conditions than they are for chronic conditions. The reality is you’re going to be treating chronic conditions, so let’s get there.

Second of all, we need communication. Not all schools hammer communication in course of itself. Since COVID, we needed even more because many of those students had been online for so long. We’re talking about some basic verbals and non-verbals, but now I’m going to be taking it to empathy and trust, and recognizing it’s not an interpersonal issue alone. We’ve got these bigger factors. I want depth in communication.

Finally, I want foundational training in marginalization, much like nursing and some of these other ancillary professions do. You need to understand what happens with these social determinants of health from an experiential level. We can talk about it all you want, but until you have to make a decision on whether you’re going to pay for healthcare or your child’s dinner that day, and truly understand that, without exploiting the story.

You have to build some empathy through some experiential things. We grew up under a medical model. My PhD is through the University of Togo and so the physios and the UK model grew up under OTs and nursing. They have a foundational difference in the way they approach training. We need to expand our horizons. We then have to do it post-professionally because culturally, we judge pain poorly. Yet in my surveys and the other reviews, we think we can judge somebody’s severity as well as they can. We can’t. When we do think that, then that’s going to set us off on other problems.

HPP 304 | Marginalization Of People
Healthcare education needs a foundational training in marginalization. Healthcare professionals need to understand what happens with social determinants of health from an experiential level and build empathy.


I’m laughing and smiling with you because I came back from Texas. I had the opportunity to collaborate with and teach the DPT faculty at Texas State University in Round Rock, which is outside of Austin. Janet Bezner invited me, and I’m grateful to her for the invitation. I was putting together a two-day pain science and pain education lecture. I was looking at all these topics around marginalization and vulnerability. I spent a pretty good amount of time probably close to 2 to 3 hours in a two-day course on that.

When people first enter the room, everyone is excited to learn about pain mechanisms and pathways, “What is the one psychosocial factor I should be screening for,” and things like that. I take them on a little journey of, “Now that you understand what’s happening at the cellular level, and you understand some tracks, parts of the brain, and how to screen for certain things, let’s now talk about people.” It resonates with a lot of people because they know inherently, “I’ve come from an education process. I’ve studied neuroscience. I’ve studied neurophysiology. I’ve studied neuroanatomy,” and all these things. What it comes down to is we work with people. We don’t work with nerves.

That’s the important part. That’s why I always tell my students, “I want you to see the humanity in front of you. See that person understands it. Learn from my mistakes because I used to jump right in.” I still feel guilty for those patients I didn’t help. Did I put them on this medicalized path of poverty because it was my misguided assistance that wasn’t needed?

Healthcare providers must see the humanity in front of them. They must help patients understand it instead of simply jumping right in. Click To Tweet

I also did a number of exercises around co-regulation and how that builds the therapeutic alliance. For some people, it’s the first time they were introduced to some of those things. I had them work with topics that are easy to talk about and difficult to talk about. It’s interesting to see that a lot of physical therapists are looking for these skills and for permission to do work on a deeper level, which a lot of your research supports. It’s like, “Let’s have these deeper conversations. Let’s figure out how we can bring them over into DPT education and clinical practice.”

Those are the patients I succeeded with. When you were able to get to those conversations, then it’s totally different.

Alicia, it has been wonderful speaking with you. Everyone is going to enjoy this episode. They’re going to share it with their friends and colleagues all over social media. You can find me on Instagram @DrJoeTatta. How can people learn more about you and follow your work?

I am on Twitter, @AliciaE_Physio. You can also find me at the High Point University Pro Bono Physical Therapy Clinic or you can email me at [email protected].

Make sure you share this episode and tweet out to Alicia and let her know that you appreciate her work and her efforts here. I’m Dr. Joe Tatta, we’ll see you next time. Take care.

Thank you very much.


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About Alicia Emerson, PT, DPT, MS, OCS, FAAOMPT

HPP 304 | Marginalization Of PeopleAlicia J. Emerson, PT, DPT, MS, OCS, FAAOMPT, is an Assistant Professor and Director of Clinical Practice in the Department of Physical Therapy at High Point University, High Point, NC. She is currently a PhD student at the University of Otago, New Zealand. Dr. Emerson is also the director of High Point University’s Pro Bono Physical Therapy Clinic. This unique clinic is open 40 hours per week.

She is a Board Certified Orthopaedic Clinical Specialist and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. Dr. Emerson created and co-directs a foundational Pain Science course, and in addition directs Community Outreach courses.

Dr. Emerson’s research interests include understanding the sociopolitical influences on chronic musculoskeletal pain management & outcomes, discerning the functional implications of pain processing in the management of musculoskeletal conditions, and advancing clinical reasoning in complex patient management to minimize inequitable outcomes.

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