LGBTQIA+ Cultural Competence in Physical Therapist Education and Practice: A Qualitative Study from the Patients' Perspective.

OBJECTIVE: The purpose of this study was to explore the experiences of cultural competence and humility among patients of the lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) community in physical therapy. Researchers sought to understand the perspectives of adults over 18 years old who have received physical therapy and identify as a member of the LGBTQIA+ community. METHODS: A phenomenological qualitative approach was utilized for this study. Patients were recruited through social media and LGBTQIA+ advocacy organizations across the United States. Twenty-five patients agreed to participate in the study. Focus groups and individual interviews were conducted using a semi-structured interview guide informed by Campinha-Bacote's domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, discussions, thoughts, perceptions, and opinions. RESULTS: Three central themes and subthemes emerged from the data and were categorized according to cultural acceptance (societal impact, implicit and explicit bias), power dynamics between the in-group and out-group (out-group hyperawareness of their otherness), and participant solutions (policy, training, education). CONCLUSION: An LGBTQIA+ patient's experience is influenced by the provider cultural acceptance, and the resulting power dynamics that impact LGBTQIA+ patients' comfort, trust, and perceptions of care. Enhanced patient experiences were found more prevalent with providers that possessed elevated levels of education or experience with this community, supporting Campinha-Bacote's assumption that there is a direct relationship between level of competence in care and effective and culturally responsive service. IMPACT: Awareness of the underlying issues presented in these themes will assist in the development of effective solutions to improve LGBTQIA+ cultural competence among physical therapists and physical therapist assistants on a systemic level.

Orthopaedic Manual Physical Therapy: A Modern Definition and Description.

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

LGBTQIA+ Cultural Competence in Physical Therapy: An Exploratory Qualitative Study From the Clinician's Perspective.

OBJECTIVE: The purpose of this study was to understand the lesbian, gay, bisexual, transgender, queer, intersex, agender, and other gender and sexually diverse identities (LGBTQIA+) health care experience and associated cultural competence from the physical therapist perspective (physical therapist and physical therapist assistant). METHODS: An exploratory qualitative approach implementing semi-structured focus groups and private interviews was utilized. To further anonymity, researchers allowed subjects to keep their camera off on Zoom. An interview protocol included questions guided by Campinha-Bacote domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, stories, discussions, thoughts, and opinions. Physical therapist clinicians were recruited from the clinical education affiliation lists of Regis University and Thomas Jefferson University. Seventy-one practicing physical therapists from the USA agreed to be part of the study. RESULTS: Themes were organized using the Social Ecological Model Framework. Themes are in parentheses following each level of the Social Ecological Model and include intrapersonal level (psychological stress and implicit and explicit biases), interpersonal (acceptance and competency), organizational (experience), community (advocacy), and society and policy (explicit biases and policy). CONCLUSION: Cultural competence in physical therapy is influenced by intrapersonal, interpersonal, organizational, community, and social and policy factors. Themes of psychological stress, limited awareness, decreased acceptance, and competency as well as limited exposure and experience, and a lack of advocacy and broader societal and policy issues prevent adequate LGBTQIA+ cultural competency of physical therapist providers. Further research in the physical therapist profession is needed to elaborate on the student, educator, and patient perspectives and how this information informs the LGBTQIA+ cultural competence of clinicians. IMPACT: This project may have a significant impact on suggestions for the delivery of content for health profession education to best impact health equity goals and save lives. Implementation of this content may have a direct impact on health disparities in LGBTQIA+ populations by reducing stigma and discrimination from health care providers, thus improving quality of health care and decreasing rates of patient mortality for LGBTQIA+ individuals.

Turning toward suffering: Rethinking the patient- clinician relationship in physical therapy practice.

In this professional theoretical article, the authors argue that patient care should be centered on connection and that authentically turning toward suffering necessitates an approach to care that transcends medicine's traditional focus on cure and physical restoration and differentiates between pathology and disability. The meaning of illness and suffering for those who have experienced life-changing injuries or illness is explored. Strategies for approaching the lifeworld of these individuals are discussed using the concepts of phenomenology and embodiment, rooted in the work of philosophers from the phenomenological tradition. The authors also propose an approach to patient care offering a case-based example based on postmodernist concepts that elevate connection, relationship, and interdependency above the traditional focus of restoring normality and physical independence for individuals with disabilities. Traditional assumptions about quality of life, illness, and disability are called into question by focusing on the fluidity of being and disability identity, which serves to destabilize static, binary conceptions of individuals as either healthy or ill, disabled, or able-bodied. A postmodern lens invites healthcare practitioners to envision themselves as part of an assemblage that may promote a more expansive view of the relationship between patient and healthcare practitioner.

Forming Physicians: Evaluating the Opportunities and Benefits of Structured Integration of Humanities and Ethics into Medical Education.

This paper offers a novel, qualitative approach to evaluating the outcomes of integrating humanities and ethics into a newly revised pre-clerkship medical education curriculum. The authors set out to evaluate medical students' perceptions, learning outcomes, and growth in identity development. Led by a team of interdisciplinary scholars, this qualitative project examines multiple sources of student experience and perception data, including student essays, end-of-year surveys, and semi-structured interviews with students. Data were analyzed using deductive and inductive processes to identify key categories and recurring themes. Results suggest that students not only engaged with the curricular content and met the stated learning objectives but also acknowledged their experience in the humanities and ethics curriculum as an opportunity to reflect, expand their perceptions of medicine (and what it means to be "in" medicine), connect with their classmates, and further cultivate their personal and professional identities. Results of this qualitative study show how and in what ways the ethics and humanities curriculum motivates students past surface-level memorization of factual knowledge and encourages thoughtful analysis and evaluation about how the course material relates to and influences their thinking and how they see themselves as future doctors. The comprehensive qualitative approach reflects a holistic model for evaluating the integration of humanities and ethics into the pre-clerkship medical education curriculum. Future research should examine if this approach provides a protective factor against the demonstrated ethical erosion and empathy decrease during clinical training.

Crises as the Crucible for Change in Physical Therapist Education.

This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.

Competency-Based Education and Practice in Physical Therapy: It's Time to Act!

Competency-based education (CBE) is a concept, a philosophy, and an approach to educational design where learner progression occurs when competency is demonstrated. It assumes a set of standard defined performance outcomes for any level of professional practice-students, residents, or practicing physical therapists. Those outcomes are based on the health needs of society and guide the curricular design, implementation, and evaluation of health professions education programs. Lack of a CBE framework-with no required demonstration of competence throughout one's career-has the potential to lead to variation in physical therapists' skills and to unwarranted variation in practice, potentially hindering delivery of the highest quality of patient care. CBE requires a framework that includes a commonly understood language; standardized, defined performance outcomes at various stages of learner development; and a process to assess whether competence has been demonstrated. The purpose of this perspective article is to (1) highlight the need for a shared language, (2) provide an overview of CBE and the impetus for the change, (3) propose a shift toward CBE in physical therapy, and (4) discuss the need for the profession to adopt a mindset requiring purposeful practice across one's career to safely and most efficiently practice in a given area. Utilizing a CBE philosophy throughout one's career should ensure high-quality and safe patient care to all-patient care that can adapt to the changing scope of physical therapist practice as well as the health care needs of society. The physical therapy profession is at a point at which we must step up the transition to a competency-based system of physical therapist education.

Norwegian physiotherapy teachers' experience from working in a partnership project in Sudan - A case study approach.

INTRODUCTION AND AIMS: Professionals working abroad as part of a partnership program is a central act of internationalization among higher education institutions. Little research has been carried out on this topic. The goal of this study was, therefore, to explore, describe and discuss the workplace learning factors - especially cultural factors - influencing Norwegian physiotherapy teachers, working in an international partnership project at a women's university in Sudan. METHODS: The study had a qualitative case-study design, intended to provide an in-depth understanding of workplace learning processes. We used a multifaceted approach which included individual interviews and document analyses. RESULTS: We identified individual, social and institutional factors that influenced workplace learning. Culture is decisive at all levels, and knowledge, skills and attitudes are culturally situated. The Norwegian teachers' learning was found to be dependent on both internal and external factors and the pre- and post-project periods. CONCLUSION: This study shows that a workplace perspective on the experience of Norwegian physiotherapy teachers gives us a better understanding of the important factors, associated with such a project. Working abroad not only requires preparation on the part of the sending and host institution but also from the person working abroad (prior to, during and after the stay abroad) if workplace learning is to occur.

Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective.

Clinical reasoning errors in health-care can be mitigated with the use of systematic strategies and tools. One of these strategies is the SINSS construct, an acronym for Severity, Irritability, Nature, Stage, and Stability. The construct of SINSS appears in several textbooks and peer-reviewed articles. However, it has been inconsistently defined and applied in clinical practice. In this clinical perspective, the terms of the SINSS construct are defined in detail and their application to clinical practice is discussed. Current research showing the application of SINSS as a whole in clinical practice and educational settings is also presented. Recommendations for future application of SINSS are provided to advance the study of clinical reasoning and help minimize diagnostic, prognostic, and interventional clinical errors. The systematic use of SINSS allows the clinician to gain a thorough understanding of the patient's condition and symptoms, which can lead to a well-tolerated and appropriately tailored physical examination and intervention. Additionally, the proper use of this construct can result in more optimal patient outcomes, as well as provide a structure for the mentor and learner in helping uncover errors in the learner's clinical reasoning process.

Gains in insurance coverage following the affordable care act and change in preventive services use among non-elderly US immigrants.

Immigrants have lower and disproportionate use of preventive care. We use longitudinal panel data to examine how the 2014 full implementation of the ACA mandates affected change in preventive services (PS) use among immigrants that gained insurance. We used data on Foreign-Born (FB) and US-Born (USB) adults, ages 26-64 years, from the 2013/16 Medical Expenditures Panel Survey longitudinal files to examine within-person change in yearly utilization of age/sex specific United States Preventive Services Task Force (USPSTF) recommended services. We included five primary care (e.g., influenza immunization), three behavioral (e.g., diet), and seven cancer screening (e.g., mammography) measures. We used generalized estimating equations and difference-in-differences tests to assess the effects of insurance gain on: (1) change in PS utilization, and (2) reduction in utilization disparities between USB and FB adults, adjusting for predisposing, health enabling, and health needs factors. Our results showed that newly-insured FB adults substantially increased their use of all primary care checks, and exercise and diet advice. We also found improvements in use of endoscopies, two modalities of colon cancer screening, and prostate cancer screening, but not in receipt of mammography and clinical breast exams. Newly-insured FB PS use remained lower than use among continuously-insured USB adults, but some of the differences were explained by adjustment to enabling and health needs factors. Briefly, health insurance gains among immigrants translated into substantial improvements in use of recommended PS. Still, notable disparities persist among the newly-insured FB, and more so among the 1 in 5 that remain continuously uninsured.

Racial/Ethnic Differences in Mortality in Late Midlife: Have They Narrowed in Recent Years?

OBJECTIVES: To examine whether racial/ethnic differences in mortality rates have changed in recent years among adults in late midlife, and if so, how. METHODS: We analyze Health and Retirement Study data on non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks), and English- and Spanish-speaking Hispanics (Hispanic-English and Hispanic-Spanish), aged 50-64 from 2 periods: 1998-2004 (Period 1, n = 8,920) and 2004-2010 (Period 2, n = 7,224). Using survey-generalized linear regression techniques, we model death-by-end-of-period as a function of race/ethnicity and sequentially adjust for a series of period-specific baseline risk factors including demographics, health status, health insurance, health behaviors, and social networks. Regression decomposition techniques are used to assess the contribution of these factors to observed racial/ethnic differences in mortality rates. RESULTS: The odds ratio for death (ORD) was not statistically different for Blacks (vs. Whites) in Period 1 but was 33% higher in Period 2 (OR = 1.33; 95% confidence interval [CI] = 1.05-1.69). The adjusted ORD among Hispanic-English (vs. Whites) was not statistically different in both periods. The adjusted ORD among Hispanic-Spanish (vs. Whites) was lower (ORD = 0.36; 95% CI = 0.22-0.59) in Period 1 but indistinguishable in Period 2. In Period 1, 50.1% of the disparity in mortality rates among Blacks was explained by baseline health status, 53.1% was explained by financial factors. In Period 2, 55.8% of the disparity in mortality rates was explained by health status, 40.0% by financial factors, and 16.2% by health insurance status. DISCUSSION: Mortality rates among Blacks and Hispanic-Spanish have risen since the mid-1990s. Hispanic-Spanish may be losing their advantageous lower risk of mortality, long known as the "Hispanic Paradox."

Changes in Insurance Coverage and Healthcare Use Among Immigrants and US-Born Adults Following the Affordable Care Act.

OBJECTIVES: Immigrants to the USA have disparate access to health insurance coverage and healthcare services. We evaluate the effects of gaining insurance following the January 2014 Affordable Care Act's (ACA) key provisions implementation on health services use among foreign- (FB) and US-born (USB) adults. METHODS: Longitudinal data from two panels (2013/2014 and 2014/2015) of the Medical Expenditure Panel Survey on FB and USB adults, ages 26-64 (unweighted n = 15,232), and difference-in-differences analysis using generalized estimating equations were used to estimate the effects of insurance gain. The primary outcomes were five measures of healthcare utilization including yearly routine care appointment, annual number of physician office visits, annual number of prescription medications filled or refilled, use of the emergency department (ED) during the year, and having an inpatient hospital stay during the year. RESULTS: Immigrants were more likely to gain health insurance between 2013 and 2015 relative to USB adults (6.3% vs. 4.4%) but remained much more likely to be continuously uninsured by 2015 (20.8% vs. 6.4%). Controlling for sociodemographic and health characteristics, FB and USB adults who gained insurance increased their use of health services, including routine care (absolute change ΔFB = 15.7%; p < 0.001 and ΔUSB = 11.7%; p < 0.001), office-based doctor visits (ΔFB = 1.3; p < 0.001 and ΔUSB = 0.6; p < 0.001), prescribed medications (ΔFB = 2.5; p < 0.001 and ΔUSB = 1.6; p = 0.016), and inpatient hospitalizations (ΔFB = 3.6%; p = 0.017 and ΔUSB = 3%; p < 0.001). ED use increased only among the FB (ΔFB = 4.8%; p < 0.001). Gaining insurance eliminated the differences in health services use for all considered outcomes among the FB relative to the continuously insured USB. CONCLUSIONS: US immigrants had notable gains in health insurance after the ACA provisions took full effect, but major disparities in coverage persist. If insurance continues to expand among immigrants, then the gains may reduce longstanding disparities in health services use and enhance primary and preventive healthcare.

Medicaid managed care and preventable emergency department visits in the United States.

OBJECTIVES: In the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use. METHODS: Using data from the 2003-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting. RESULTS: We found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy. CONCLUSIONS: Within the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.