This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Implicit bias happens whenever people unconsciously act on ingrained prejudice and stereotypes without intending to do so, and its consequences can be particularly severe in the health care setting.

"African-Americans and Hispanics are less likely to receive cardiac medications, undergo certain procedures, and receive transplantation. There is also a lower quality of basic clinical services such as intensive care," says Mariah Martin, a facilitator of Michigan Department of Health and Human Services (MDHHS) implicit bias workshops. "Stereotypical judgments about populations of color can contribute to health care disparities. When providers make quick assumptions about an individual, that can make a huge difference and lead to life-or-death decisions."

Mariah Martin.

The state of Michigan is currently undertaking a major effort to address implicit bias in its health care sector. In July, Gov. Gretchen Whitmer signed Executive Directive No. 2020-7, directing the Michigan Department of Licensing and Regulatory Affairs (LARA) to develop rules requiring implicit bias training for health care professionals licensed and registered in the state. Following a recommendation from the Michigan Coronavirus Task Force on Racial Disparities, the directive seeks to combat racism felt across the health care sector. More than 400,000 current health care providers and clinicians and 30,000 new licensees will take part in the training.

The state convened a workgroup from August to October to develop the implicit bias training model. Workgroup members represented 86 Michigan organizations including insurance providers, hospitals, health care associations, legislators, state agencies, higher education, and community and advocacy groups. Over the eight-week period, they researched examples of other states' implicit bias training programs, discussed proposed training requirements, and developed recommendations.

On Oct. 30, the workgroup forwarded its final report to LARA's Bureau of Professional Licensing. The report made several recommendations on how to implement the new requirement, scope of the training, and how the state could partner with other organizations to research and evaluate the impact.

David Harns, interim communications director for LARA's Department of Licensing and Regulatory Affairs, says the Bureau of Professional Licensing will now draft rule language, conduct a cost-benefit analysis, provide an analysis of how the rule changes impact citizens and state agencies, and hold a public hearing to receive comments and feedback on the proposed rule. The department will then forward the rules to the state legislature to be considered by the Joint Committee on Administrative Rules, after which LARA will be able to formally adopt and implement the implicit bias training requirement.

Amber Bellazaire.

"Increasing awareness of and improving our responses to unconscious biases is a really important step in the process of advancing impartial and culturally responsive health care in Michigan," says Amber Bellazaire, policy analyst for the Michigan League for Public Policy, one of the workgroup's member organizations. "This directive provides necessary uniformity across health care systems and providers. Research on implicit bias training's effectiveness is ongoing but it does suggest we can reduce our reliance on stereotypes."

MDHHS takes the lead

Although the current work to implement a statewide implicit bias training model for health care workers is a major step forward, the need for implicit bias training has long been established in Michigan and across the nation. The 2018 National Healthcare Disparities Report found that white patients receive higher-quality health care than Black, Hispanic, Indigenous, and Asian-American patients. People of color face more barriers to getting health care and are less satisfied with how providers interact with them. In Michigan, these disparities result in more Black people dying in the first year of life; during pregnancy and childbirth; and from heart disease, stroke, cancer, and HIV/AIDS.

In October 2019, MDHHS rolled out mandatory online training to address systemic racism and health equity for all of its staff. After completing the online segments, facilitated small-group sessions provided an opportunity to converse, ask questions, and dive deeper. In 2020, implicit bias training was added for all MDHHS staff involved in hiring. By the end of this year, all MDHHS staff will participate in implicit bias training.

"Presenting implicit bias training to all of our state workers gives us a common language to help folks get an awareness that they didn't have before. It allows them to get comfortable with the conversation and see where actions need to take place," says Katie Saputo, who facilitates implicit bias workshops for MDHHS. "It forces us to look at the areas where we need to make change and gives us the language to change those policies and practices that are happening throughout the state in health care and at MDHHS."

Katie Saputo.

"Implicit bias training is a very important first step but it is just that: a first step. Other things need to happen in order for that institutional change to happen," Martin adds. "We really need to address policies and procedures, building a culture that has equity at the forefront, and also evaluation. Is this training working? Are behaviors changing? Is what we're doing having a positive impact on populations of color?"

Building empathy, writing policy, and shifting culture

In addition to MDHHS' implementation of implicit bias training for its staff, many of Michigan's health care systems had already made their own implicit bias training available to providers and staff prior to Whitmer's directive. With expertise in training educators and health care professionals about a trauma-informed approach to their work, Albion-based Starr Commonwealth has long included implicit bias as a topic in its curricula. Gregg Strand, Starr's director of strategic partnerships, agrees with Martin that overcoming implicit bias will take more than completing an online course.

"It can't be a one-and-done training," he says. "What we're after is that long game. We would challenge the state, the governor, and health care institutions to not settle for just checking a box."

Erin Reed.

"The more reflective work an individual does to see the way they are in the world, the more they are going to be informed with all their interactions," adds Erin Reed, Starr's senior trainer. "With anyone, it's about building that empathy. The cornerstone of empathy is curiosity: 'Wow! There are other people out here in the world and they are having different experiences than what I am.' Instead of being the all-knowing professional who diagnoses, prescribes, and moves on, providers need to get super-curious about this other person's experience."

Reed notes that the experience of racism is trauma. To be sick or injured, and then mistreated by a health care professional, exacerbates that trauma and can create barriers to wellness.

"We have to raise awareness about how this baked-in bias is part of white supremacist culture. Until we peel back the layers, we are constantly looking through lenses of whiteness as normal and others as less worthy," Reed says. "In behavioral health and mental health, a Black woman's depression is more likely to be seen as anger or being anxious instead of what is actually happening. Equity in our society is not there. Inequity is a fact and is having impacts on the brains and bodies of everyone experiencing it."

In trainings, Reed helps professionals look at how their social identities show up on the job. She sees understanding one's own social identity and how it plays out as crucial to the healing process.

"If that health care provider is living in that system of toxic hierarchy, they are bringing that out onto their patient," Reed says. "There is so much history with inequities in health care in our country that we have to be aware of. There is a lot of very well-founded mistrust carried on from generation to generation. The first thing providers must do is earn the trust of people who look different than them. Then, healing is more possible."

With its new implicit bias training requirement, the state aims to help more providers do just that. Bellazaire describes the Michigan Coronavirus Task Force on Racial Disparities as "a positive example that the government can do things to address and reduce racial disparities," and expresses hope that the implicit bias training effort will be another.

"The training and curriculum utilized will ultimately have a broad focus to ensure that the ways in which other populations may currently be receiving care differently will be reduced," she says. "This will increase opportunity for doctors and health care providers to unlearn any kind of implicit bias, which we all carry, and likely improve wellness for all Michiganders."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Mariah Martin and Katie Saputo photos by Doug Coombe. Amber Bellazaire photo courtesy of Amber Bellazaire. Erin Reed photo courtesy of Starr Commonwealth.