Cultural Sensitivity.

To the Editor:

There is something about a millennium that seems to demand retrospection in those about to begin it. Perhaps it is the realization that, for all of us practicing today, there will never be the chance to experience another turn of the century in our lifetime. Perhaps we are seized with a sense that, no matter how many improvements have occurred during the past century, our profession still has so much untapped potential to offer to our patients. Whatever the reason, it is almost impossible not to succumb to the urge to reminisce about our profession. Even the most cursory look backward will show many important areas of growth. Much has been written about the move toward evidence-based intervention, expansion of practice boundaries, and increased recognition by other professions. Although those areas have resulted in many important and exciting developments, it is important not to overlook another area of growth that may seem to be more low key but that can have a dramatic impact on the way we practice.

Physical therapy has always held its practitioners to the highest standards of professionalism. The creators of the American Physical Therapy Association's Code of Ethics found the concept that "Physical therapists respect the rights and dignity of all individuals"[1] was so compelling that it was selected to be the first principle. Over the past 2 decades, there has been increased emphasis placed on the need to incorporate more respect for patient dignity and autonomy into health care interactions. This has gradually resulted in a more culturally sensitive approach to patient care. Although the term "political correctness" is used derisively by some to describe such attitudes, it is important to remember that the second word of the phrase is "correctness." As physical therapists, we have known since the beginning that a patient was far more than the sum of his or her disabilities. The illness-based biomedical model was never a comfortable fit for our work because one of our profession's primary goals was to prepare patients to return to their community role in the least restrictive environment possible. We found this impossible to accomplish without accepting the patient as part of the health care team. Our skill may be the catalyst for recovery, but it is the patient's body, the patient's insurance dollar, and the patient's future that are taking all of the risk. In this era of risk management, it has been well established that those who assume the greatest risk expect to have some access to the decision making. However, allowing patients onto the team and making it possible for them to feel comfortable expressing their goals are two very different things, and one does not automatically beget the other. Without a heightened awareness of the need for cultural sensitivity in our patient interactions, the patient will never really be able to participate as an equal on the team.

The health care consumers of the 21st century look very different from those receiving care at the start of the last century. Demographics show that people representing a tremendous variety of races, cultures, and socioeconomic levels are now seeking access to a medical system that in many ways is ill-prepared to serve them.[2] Evidence-based interventions alone will not guarantee effective outcomes unless therapists are able to engage the patient in the rehabilitation efforts. In the past, it has sometimes been comfortable to adopt the attitude that "It doesn't matter who my patient is because I work very hard to treat everyone in the same manner." This attitude implies that as long as the provider feels comfortable that care is evenhanded and unbiased, it will be so. However, the comfort of the physical therapist is only half of the equation. The patients should also feel comfortable, and that attitude is more likely if their care takes into consideration personal beliefs, practices, and needs. One size never did fit all, and that was never more true than in the area of health care.

Cultural sensitivity is a difficult concept because it requires us to admit that each of us possesses biases, even if only due to ignorance. It is even harder to acknowledge that the result of both intentional and unintentional cultural insensitivity is the same: Our patients are denied the chance to fully benefit from our professional expertise.[3] Introspection is never comfortable, but the profession has not shied from it. Cultural sensitivity has been identified as an important theme to be woven throughout a curriculum,[4] rather than just a mandatory content area to be quickly disposed of in an isolated workshop or lecture. Increased availability of continuing education courses, keynote conference speakers, diversity in student and faculty populations, and insistence on people-first language in articles and presentations will make it possible for all therapists to slowly work toward achievement of the first principle outlined in our Code of Ethics. This has not been easy, because it requires change. Each practitioner who has ever watched his or her own family member enter the medical system as a patient knows that there is a long way to go before the patients are consistently accorded the respect and dignity they deserve. This is truly a journey of a thousand miles that has only just begun, but physical therapists have seen the need and already have been willing to take the first step on the road. Who knows how far we will be able to travel before the next millennium?

Denise G Bender, PT, MEd, GCS Assistant Professor Department of Physical Therapy School of Medicine University of Maryland at Baltimore 100 Penn St Baltimore, MD 21201

References

[1] Code of Ethics. Alexandria, Va: American Physical Therapy Association; 1999.

[2] Babyar SR, Sliwinski M, Krasilovsky G. Survey of inclusion of cultural and gender issues in entry-level physical therapy curricula in New York State. Journal of Physical Therapy Education. 1996;10(2):53-62.

[3] Guide to Physical Therapist Practice. Rev ed. Alexandria, Va: American Physical Therapy Association; 1999.

[4] Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Educational Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1998.