The pandemic was devastating on many levels. As of this writing, there have been 82.3 million cases of SARS-CoV-2 resulting in 1 million deaths in the United States alone. Nearly 20% of Americans know someone who has died of the disease, according to a survey from the Associated Press-NORC Center for Public Affairs Research at the University of Chicago. The figures below are from American Public Media Research Lab’s “The Color of Coronavirus” reporting. The pandemic accomplished something virtually nothing else has managed to accomplish; it put in stark relief something public health experts and social scientists have known for years, if not decades. The pandemic proved health inequities are real, complex, and tenacious.
To better address health inequities, Governor Gretchen Whitmer announced in June 2021 the promulgation of Rule 338.7001 for Michigan’s healthcare workforce. The rule requires licensed healthcare workers receive at least one hour of implicit bias training.
WHY implicit bias training?
Implicit bias should not be confused with racial animus or racism. It’s not even specific to race. It is a heuristic process, hardwired into our brains to manage information. Humans receive unmanageable amounts of information with every human interaction. In fact, it is estimated humans receive around 11 million pieces of information at any given moment. Heuristic processes, like implicit bias, help us make decisions instantaneously by making associations with existing knowledge and filling in missing information.
For example:
Jane is exiting an elevator into a parking garage when she notices a stranger standing in the distance. In that moment, she makes the instantaneous decision to stay on the elevator and return to a more populated, brightly lit space. The person did not threaten her. The person did not even appear to notice her. She returns to the lobby of the building and waits for a friend to accompany her back to the parking garage.
Why did Jane hesitate? There was no data in that moment to support her hesitation. Her response was based on her personal experiences, her exposure to certain types of media, and an association of parking garages with danger. While your conscious mind was at work listening to the story, your unconscious mind was also busy filling in the missing details. Did you visualize the setting? Was it dark? Was the garage mostly empty? Did you envision a man in the parking garage? What did Jane look like? Was she young or old? Those details were not given, but your mind filled them in. Those are implicit biases. Not all implicit biases are harmless.
Implicit biases in a healthcare setting can impact outcomes and participation in the healthcare system. This became abundantly clear in 2021 when the SARS-CoV-2 vaccines first became available. Despite African Americans being affected by the virus in greater numbers, vaccine rates in that population lagged behind their White counterparts. The lower vaccine rates were attributed to two factors: access and hesitancy. Historical traumas, institutional racism and “neglect and inadequate treatment in healthcare settings” resulted in distrust of the system.
In Michigan, the infant mortality rate for African American infants is nearly 3 times what it is for White infants. Additionally, Black birthing persons are three times more likely to die from pregnancy-related causes than their White counterparts, according to Michigan Department of Health and Human Services 2020-2023 Mother Infant Health & Equity Improvement Plan. The report cited social determinants of health to be at the center of the disparity. The obstacles to improved outcomes for mother and child include poverty, discrimination, access to good jobs with fair pay, quality education and housing, safe environments and healthcare.
Studies show many identity dimensions are affected by bias in healthcare settings. The US Department of Health and Human Services 2019 National Healthcare Quality and Disparities Report (2020) identified for about 40% of quality measures, Black, Indigenous, and People of Color (BIPOC) received worse care than White Americans.
A literature review from 2018 examined gendered pain management and biased attitudes toward women’s pain in the patient-provider encounter. These encounters resulted in dismissing women’s pain and characterizing women in pain as emotional, hysterical, or sensitive while men in pain were characterized as “brave”.
Despite commitments to quality care, 50% of first year medical students expressed explicitly negative attitudes toward the LGBTQ community and 80% returned negative evaluations based on implicit biases, according to a systematic review of training programs. These biases result in healthcare avoidance in the short term and higher rates of cancer, cardiovascular disease, substance abuse, and suicide among other health-related problems in that population in the long term.
A 2017 qualitative study investigating ageism found providers were more likely to find older patients to be non-compliant, helpless, and demanding. Some of these providers withheld treatment options for older adults out of a concern the treatment would be too aggressive. This study found physicians are less likely to involve the patient in their decisions which contributed to the patient feeling invisible. Further, physicians in this study reported the existence of suicidal tendencies among older adults as normal and logical and were less likely to offer therapeutic interventions.
Health disparities and inequities are pervasive across identity dimensions. There are data to show biases affect health outcomes for obese patients, neuro-divergent patients, and patients with disabilities, patients who are immigrants or speak a language other than English, patients living in poverty, and on and on. Developing self-awareness and a sense of humility is essential to remediation. Implicit bias training encourages those qualities.
WHO must get implicit bias training?
The short answer is all licensed healthcare professions except veterinary medicine.
The guidelines for compliance are complicated and have resulted in some confusion. New applicants for licensure must have two contact hours within five years leading up to the issuance of their first license. For the first renewal (beginning June 1, 2022), all licensed healthcare workers who renew their license must have at least one contact hour of implicit bias training per year since June 1, 2021.
For the second renewal and each renewal thereafter, licensees must have one contact hour per year of the licensure cycle. That is to say, if the renewal cycle is every two years, the requirement is two hours. If the cycle is three years, the requirement is three hours. This is in addition to any other continuing education requirements each licensee must meet to renew their license.
Read the FAQs here.
HOW must the training be delivered and by whom?
Implicit bias training must be live so participants can engage with each other and the instructor. Pre-recorded webinars or e-learning modules are insufficient to meet the mandate. The content must be delivered by or sponsored by a health-related organization, a state or federal agency, an educational program, college or university, or an organization specializing in Diversity, Equity, and Inclusion (DE&I) issues.
Participants are required to undertake a self-assessment before and after taking implicit bias training. The Harvard Implicit Association Test is a popular one.
The training must include a wide range of topics including information on implicit bias, health equity, diversity and inclusion, and cultural sensitivity. The training should include strategies to remedy the impact of negative biases and provide tools to recognize how bias impacts perception and decision-making. It should include some history of how biases have impacted individuals in the past and how the consequences of bias impact individuals today. The training should also include current research.
All of these objectives go toward accomplishing a sense of cultural humility. The Hogg Institute of the University of Texas lists three main tenets of cultural humility:
Culture: the understanding that individuals operate within multiple cultures throughout their daily lives and frequently traverse boundaries between those cultures as they move between home, work, social, and other settings.
Self-reflection: the idea that cultural humility comes with examining one’s own beliefs and experiences.
Historical awareness: the notion that a person must be aware of and sensitive to the historical realities and legacies of violence and suppression against members of other groups.
WHERE can you get implicit bias training?
Professional associations frequently offer continuing education at their annual conferences and many have opted to include implicit bias training or DE&I training as part of their CE offerings. Further, many forward-thinking employers have included this kind of training as part of their on-boarding or continuing education offerings because cultural humility aligns with their mission and values.
There are roughly 400,000 healthcare workers in Michigan; many of them work independently and do not belong to an association. Many cannot attend conferences due to scheduling conflicts or work demands, especially while COVID variants continue to emerge. How can those professionals find training?
Michigan Health Council offers ongoing implicit bias training. Our mission is to build capacity for the healthcare workforce. That is, to have the right person, with the right skills, in the right place, at the right time. The Implicit Bias Recognition and Remediation course we offer meets all of the requirements of the State of Michigan. Our implicit bias training is different from other offerings because it is taught from the perspective of the social sciences and is taught by an anthropologist. The course examines the mechanisms of implicit bias and how culture and healthcare intersect and interact with each other. Multiple identity dimensions are discussed— including race, sex and gender, and body size among others— in the context of stigma and healthcare avoidance.
Multiple options for delivery are available including a hybrid version in which participants can view a pre-recorded video and then join a live webinar for discussion of the issues presented in the video. Organizations can opt for a live, in-person or virtual presentation for their group. Please contact Kristin Sewell at [email protected] or visit the mhc.org/education to register.