Welcome back to the Healing Pain Podcast with Micheal Holder, PT, DPT
We’re discussing topics and beliefs associated with racial bias in pain management and physical therapy. It has been reported that medical students and residents hold false beliefs about the biological differences between blacks and whites. It demonstrates that these beliefs predict racial bias in pain perception and the management of effective pain care. My guest is physical therapist Michael Holder. Michael graduated with a Bachelor of Science in Exercise Physiology and a Minor in Strength and Conditioning from the University of Delaware. He went on to earn his Doctorate in Physical Therapy from Misericordia University in 2013. He works in outpatient sports and orthopedics. He holds certifications in Vestibular Rehabilitation, Functional Nutrition for Chronic Pain, and Instrument-Assisted Soft Tissue Mobilization.
In this episode, we discuss how pain is treated differently in the African-American community, who are more likely to receive pain medication, blacks or whites, pain myths and false beliefs that are still alive to this day, hurt pain and sustain pain in African-American and other people of color, challenges to accessing physical therapy and other vital health services necessary for the adequate care of pain in minorities and African-Americans. Finally, issues related to minorities and people of color in the profession of physical therapy. Let’s meet Michael Holder and discuss pain and racial bias.
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Racial Bias In Pain Management And Physical Therapy With Micheal Holder, PT, DPT
Michael, welcome to the show.
Joe, how are you? Thanks for having me.
I’m doing well. It’s been months ago when I was walking down the street in New York City and we bumped into each other on West 22nd Street. Everyone thinks that New York City is such a big place, but the truth is New York City is tiny. You’ve been in one of the courses that I’ve taught. We started talking about the topic of pain and racial bias as things have been developing in the media. I wanted to have you on to talk about this as a physical therapist. Thanks for joining me. Tell us why you wanted to become a physical therapist and what does your practice look like now?
I have a unique background growing up. I was homeschooled. My mother was a yoga teacher. My dad was a functional medicine physician. I always had medicine around me to an extent, but I always wanted more personalized care. I found PT to be that route. I have a PT myself growing up. They thought I tore my ACL and the image showed that, but they’ve found out later that it was negative. In general, I had a good experience with PT. I found that to be more of a route that I wanted to go within medicine.
Your dad is a functional medicine physician. He’s an MD. How long has he been practicing functional medicine?
It’s been a long time ever since I was very young. He used to work in the hospital in Newark, New Jersey. He left and opened up his own practice. His office is attached to the house that we grew up in. I always remember him working independently.
It’s great that he has that perspective. I’m sure that he had an influence on you going into physical therapy school. PT school is now starting to touch on topics of health promotion, nutrition and wellness. You had that going into school.
That idea was always in me. I found it very interesting that it wasn’t talked about enough because that’s such a huge part of pain, how we move, and even emotional and psychological, etc. I always thought it was very interesting that we didn’t go into more of the bio-psychosocial and nutritional aspects.
The other thing that’s not spoken about enough is pain and racial bias. In the bigger community of pain management within our smaller physical therapy community or our PT community is not so small. Can you tell us how pain is treated differently in the minority or the African-American community?
There’s a lot of information out there on it. There’s one major article that you and I have discussed in the past about pain and racial bias within the African-American community. The title of the article is Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. It’s from our research article from 2016. It discusses information with laypeople and also medical professionals. It looks at false beliefs about how black people feel pain differently than whites. That date back to a time of slavery to an extent, and how some ideals have continued and have not changed. That goes on to talk about the idea that it can result in inadequate treatment. There’s a list of questions that are in the article and discusses biological differences between blacks and whites, but not all of them are considered accurate. I’m going through those lists of questions or statements that are directly in the article.
It says, “On average, blacks age more slowly than whites. Black people’s nerve endings are less sensitive than white people’s nerve endings. Black people’s blood coagulates more quickly because of that. Blacks have a lower rate of hemophilia than whites. Whites on average have larger brains than blacks. Whites are less susceptible to heart disease like hypertension than blacks. Blacks are less likely to contract spinal cord diseases like multiple sclerosis. Whites have a better sense of hearing compared with blacks. Black’s skin has more collagen, such as it’s thicker, than white people’s skin. Blacks on average have denser, stronger bones than whites.
Blacks have a more sensitive sense of smell than whites. They can differentiate odors and detects faint smells better than whites. Whites have more efficient respiratory systems than blacks. Black couples are significantly more fertile than white couples. Whites are less likely to have a stroke than blacks. Blacks are better at detecting movement than whites. Blacks have a stronger immune system than whites and are less likely to contract colds.” Those were fifteen statements right there. Out of those 15, they have 11 of those that are false beliefs. It would be interesting if everyone goes through those questions again and think about what they think to be true or not true, or possibly untrue, possibly true. Some of them are very outrageous, and the fact that a lot of first-year medical students thought some of these were true, it can lead to a lot of poor treatment.
To clarify, 11 out of the 15 that you read are false. Can you tell us the ones that are true from that or there’s some evidence to support it?
There’s number five saying whites are less susceptible to heart diseases like hypertension than blacks, also number six, blacks are less likely to contract spinal cord diseases like multiple sclerosis. There’s number nine, blacks on average have denser, stronger bones than whites, then number thirteen, whites are less likely to have a stroke than blacks.
With regard to things like less likely to have a stroke and less likely to be susceptible to heart disease, whites versus blacks, that’s pointing towards people’s health disparities.
A lot of people of color may not have access to certain resources. That goes to socioeconomic status. In general, there is a feeling of blacks towards medicine that has not been positive. That’s because of a long history of things that have occurred over time. Even though those are considered true, they’re considered true because I think blacks don’t have the access to certain resources that other people do.
Looking at the perspective of pain management, physicians were asked these questions, “Do blacks have less sensitive nerve endings than whites do?” The majority of people who took this survey said, “Yes, blacks have less sensitive nerve endings than whites do.” With regard to the impact on chronic pain, how does that start to shape our practitioner’s evaluation and treatment of pain?
When I came to that, I specifically more saw an article say that they were underprescribed pain medication. That could lead to maybe not getting access to physical therapy in general. They may think and say they tolerate pain differently because they have less sensitive nerve endings. They may just dismiss their pain and not think about pain medication or alternative services. That leads to increased health disparity.
There are other ones on here that I thought was somewhat odd. For instance, blacks are better at detecting movement than whites. To me, that sounds completely bizarre.
It does sound bizarre but there’s a long history of stuff associated with that. That’s why often people will say blacks are more likely to get into athletics or get into sports. They say that they move better. They’re quicker. They’re better at detecting movements than whites. This stuff that we don’t know. We don’t even think about what they were saying and it continues. It’s like a spiral effect. There are a lot of things in here where you sit back and a little outrageous, but you hear it every day. You see it on TV. You see it in the media. It’s scary because that’s what’s making our implicit bias to an extent.
These started culturally that somehow have been carried over and reinforced within healthcare. It’s important to mention this one during this time of COVID, that blacks have stronger immune systems than white people do. I think about that and I’ve looking at the fallout, especially in the United States, from COVID and seeing how it’s impacting people of color. Knowing that there are physicians out there that may believe that maybe they have a better outcome because they have a better immune system or a stronger immune system.
It’s crazy that that statement is there because you see the exact opposite thing on the news or other things that say blacks don’t have access to certain resources or they are more likely to have increased health disparities. If they are more likely to have increased health disparities, how can they possibly have a stronger immune system? lt doesn’t even make sense as to why that’s even on there.
From your perspective as a physical therapist with regard to what you’ve seen in your career, with regard to minorities and African-Americans accessing physical therapy versus how whites or other populations access physical therapy. What are your perspectives on that?
I’ve worked in a lot of different settings and outpatient settings. I still have not seen a lot of people of color. I don’t know if that’s been the same with you or which settings you’ve worked. I worked in network and out network. I worked in a boutique. I’ve worked in semi-personal training settings as they would say. Very rarely that I see people of color. If there were people of color, they’re most likely 65 and older when it comes to that extent.
That’s a hard topic to talk about. I’ve asked friends and family members why they think that is? The idea is that most people of color do not feel safe within the medical profession. They’re not seeking out medical professionals. There are not that many people of color within the medical profession. If there are not that many people of color, a lot of people are going to emergency services first versus alternative services first, and then it also comes to costs. There are a lot of ideas as to why it may occur. The major reason is that there’s been a long history of people of color not feeling safe within the medical profession. That’s not the first route they’re always going to go.
When you say safe, we’re talking about people understanding them first. If other licensed health professionals think that their nerve endings are less sensitive, they don’t feel safe going into a pain management arena. There’s also the fact that there’s no one that looks like them. There’s no practitioner that looks like them within the healthcare system or at least within the physical therapy.
That’s always a twofold topic. One is there are no people that looks like them, but also the major socioeconomic status. One article that I’ve read and also I’ve asked people, there are people of color that are saying, “It’s not the fact that they’re black. It’s the fact that they also don’t have the resources to access areas.” That’s a major portion I saw. It wasn’t always just black and white. It was more, “If I was a person of color and I had a lot of money, then I could access whatever I needed.” Even though they did always say they may have to push a little bit more to access those resources. If they’re able to access those resources, having a higher status in society, then they will be okay. There’s the other side saying that inadequate minority representation within healthcare professionals causes a reduced utilization of preventative care and increase utilization of emergency services. Since more people of color are within medicine or PT in general, then the ideal education of what medicine is and what physical therapy is, isn’t being spread around.
Both you and I practice in New York City. When I think about access, I’ve seen patient deductibles that are $10,000 and copays that are $100. It deters everyone. Anyone who’s in a lower socioeconomic realm especially in New York City, it deters them completely from accessing physical therapy or any other kind of pain service.
I saw some of the deductibles that were $22,000, which is insane. I’ve honestly never seen that before. Personally, I always say physical therapy is very much a boutique or luxury service. I was speaking to a client one day and she was from New Zealand. She’s like, “Physical therapy is not boutique. It’s what everybody needs.” I was like, “In our society for some reason, it’s not a service that everybody gets or everybody is directed towards, so it’s a luxury service.” It can be costly, 2 or 3 times a week for a period of time. People of color don’t look for medicine, but then they’re going to start to look for medicine that’s costly. They don’t know the effects of it to an extent. It’s a cascade effect.
It’s an affordability hurdle that exists for many people. Let’s talk about physical therapy. I was born and raised in New York City. Some of the information I read sometimes is a little shocking to me. I come from a family that’s multicultural. I went to a school in Brooklyn that was completely multicultural. If you start to look at diversity specifically within the physical therapy profession, what do we see?
According to the APTA, this is from 2016. The workforce data showed that our profession is 90% white female. Another portion of this is approximately 34,000 students enrolled in an accredited PT program throughout the US from 2018 to 2019 academic year, 74.6% self-reported as white, 3.4% as African-American/black, and also 6.5% as Hispanic. As we know, our profession should represent the world we live in. Those numbers don’t represent America in general. If our profession isn’t representing the world we’re treating or that we’re around, then there’s going to be a skewed treatment.
The fact that it’s 90% white female is not a shock to any of us. If you go to any APTA conference, it looks like that.
It’s always going to be the majority female because that’s how the profession started.
What do you think we can do to encourage schools and directors to recruit more people of color into the profession?
I don’t know if it’s encouraging or recruiting more people. It has to start at a level below like college. It has to start in high school. It has to start in middle school. There is a bigger picture as to why the numbers are that way. There’s not enough education as to what we do on the profession. To be very honest, after I left the PT school, I still didn’t know what we did. It wasn’t until I started working that I understand it a bit more, and also the vast areas we could go into with how I want to treat. The major thing, unfortunately, is the cost to earning potential. The cost of PT education is so high, but their earning potential can be low, depending on the direction you go. It’s not something that most people of color are going to jump into if you’re spending a massive amount and your cost back is not going to be enough. People that are in lower socioeconomic areas are going to look for careers that are more lucrative. That’s a big reason as to why the people of color portion within the statistics we mentioned are not jumping to go into the PT realm. One is the education on what it is, but then the cost and earning potential is vast.
In PT school, I graduated quite a long time before you. I’m wondering when you were in school, did they go over topics like racial bias in healthcare or pain medicine since primarily we treat pain as physical therapists?
We did, but it was very minimal. It wasn’t in the school that I went to. I was also the only student of color in my class, which is in most PT schools it’s like 1 or 2 students of color. You hear things or there is this idea of people of color having or feeling pain differently. You do hear that within the school realm and it continues and goes. The crazy part is as a person of color, you hear these things and you get used to hearing it. You start to think it to yourself without knowing or researching on it. That’s why the article we read, I know they looked mainly at white people when it comes to pain and racial bias. It would be interesting to look at non-whites to see what their views are. You talk about a little bit in school, but it’s not talked about enough to erase or address people’s implicit bias.
When you reflect back on your DPT program experience, can you remember some of those themes showing up in the program?
When I was in school, especially in some classes or classmates, there was this idea that black babies’ nervous systems develop differently than white babies. I’m not sure why it was discussed or said. It gives the idea that there needs to be a different measurement system for black babies because their nervous systems develop differently. That goes back to what we were talking about before having that idea of a nervous system for people of color is different than white people. I’m not sure for you in school if you had guys talked about any of this stuff or had these discussions, but we had some of these discussions, but it was very minimal.
From your perspective as a black PT student, it must put you in a very interesting or precarious position when a fellow classmate or a professor who is saying this. Do you feel like you have to correct them or at least make them aware that what they’re saying may have some prejudice or influence that’s coming out of it?
This is the discussion that I’ve had with other classmates of color in the past from undergrad. I feel like these discussions need to happen more often or in general so people feel safe to talk about it without feeling judged to any extent. This is on both sides. I didn’t feel comfortable bringing it up or saying, “I think that’s incorrect,” when statements or something may be made. In our society and in general, within schooling, that people of color have to make themselves feel comfortable within white spaces. White spaces do not have to feel comfortable with people of color. That makes it a very iffy feeling when you’re within the school and that stuff is occurring. You may not know how to address that situation since you are the minority. You have a certain view of it but nobody else has that view.
How would you like to see pain improved in our profession with regard to racial bias? How would you like to see professional physical therapy address racial bias more deeply than it has?
2020 has forced everybody to look at their implicit bias no matter if they want to or not. I don’t know if the APTA is addressing it more. It does need to be addressed. They need to address it. People need to be more comfortable talking about these situations and talking about their implicit bias. Open conversations need to happen more. Without open conversation, you can teach somebody anything, but if somebody isn’t open to talking about it or even open to addressing their implicit bias or even their ideals of race in society, then it’s not going to go anywhere.
Many professional associations have minority special interest groups. Do we have that in the American Physical Therapy Association?
I have no idea. Do you know that?
I don’t. It’s just that we were talking about it. I thought I’ve never heard of it. I’ve never seen that advertise. I’m hoping we have one, but if it hasn’t come across your plate and it hasn’t come across my plate, I’m wondering it’s something that’s recent or if it’s something that is not promoted wildly enough throughout the profession.
It would be promoted within when you’re in schooling. In most schools, you have to join the APTA as a student. As a student and if you’re taking the box off of being African-American, they would mail something out to that extent. I didn’t hear anything about that.
When you think of the outpatient physical therapy practice or a PT group within the hospital, what can they do with regard to tests and measures to check things like bias within their own inner circle and community?
There’s something called an Implicit Association Test and it’s through Harvard. They have different ones. They have one on race. They have one on sexuality. They have one on skin tone. You go through a series of questions. It’s similar to the ones we talked about before. It’s true or possibly untrue, etc. At the end, it shows areas that are true, not true. It causes you or forces you to check your implicit bias to an extent. That’s the only one I know of. That’s as far as tests out there that will check for implicit bias. Bigger universities, hospitals and schools are just collecting data on your patients if it’s allowed. It’s seeing how many patients are of color, how many patients are white? How long are their treatment sessions? How long are they within the system, 10, 15 visits? That will be interesting to see if patients of color are treated for shorter periods of time or if their plan of care has also been shorter. There needs to be more data collected in general.
If private practice owners can do that, larger hospitals, medical centers and universities can do that as well. Michael, it’s been a pleasure speaking with you about pain and racial bias. Can you tell everyone how they can learn more about you and reach out to you?
I’m based in New Jersey and New York. You can email me at [email protected]. I’m not much into social media that much or any other aspects. I don’t have any of those, but you can always email me. It will be the easiest way to get me.
I want to thank Michael for joining me on the show. You can reach out to him if you live in New York and New Jersey. Make sure you share this episode with your friends and family on Facebook, Twitter, LinkedIn or wherever people are talking about pain and racial bias.
Important Links:
- Michael Holder
- Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites – article
- [email protected]
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