Will Implicit Bias Training Improve Health Care in Michigan?

June 1 was the start of a new era for Michigan’s 400,000-plus health care professionals, who now face a state requirement to take implicit bias training, through Michigan’s Department of Licensing and Regulatory Affairs.

“New applicants for licensure or registration will need to complete a minimum of 2 hours of training, and applicants for renewal will need to complete a minimum of 1 hour of training each year,” read the announcement on LARA’s website. “The annual training curriculum can cover a variety of topics related to implicit bias but must incorporate strategies to reduce disparities including the administration of self-assessments.”

The new requirement was not welcome in all circles.

Abigail Nobel, a registered nurse in West Michigan since 1989, and in 2018 the founder of Michigan Healthcare Freedom, sees implicit bias training as the state pushing a particular worldview on an entire profession. She worries it will push out those who hold other viewpoints.

“People shouldn’t have to wade through a swamp of state nonsense to take care of patients,” Nobel said. “Taking care of patients’ health care, I’m here to tell you, is difficult already. You have to keep up with the science. You keep up with your team members and their abilities. You keep up with your patients and what they need.

“That’s more than a full-time job,” Nobel told Michigan Capitol Confidential. “You do what it takes to care for your patients. It’s hard work, it’s consuming work, and to put more barriers in front of it is immoral.”

The state’s leading hospital trade group, on the other hand, is on board with the new requirements.

Under normal circumstances, the Michigan Health and Hospital Association, an industry group representing some 130 hospitals in the state, would prefer reforms be industry-led, not come from Lansing through laws or regulations, said CEO Brian Peters.

But for the implicit bias requirement, the association worked alongside the state in crafting it, Peters told Michigan Capitol Confidential.

Most hospitals in the association already held implicit bias training sessions, or had plans to offer them, Peters said, adding, “We can do better.”

By way of comparison, Peters credits a 2000 National Institutes of Health study, “To Err is Human: Building a Safer Health System,” for changing the way people think about medical errors. The study estimated that medical errors kill 98,000 people per year. Within the association and across the field, hospitals and doctors and nurses began to think about how they could lower those numbers.

“To Err is Human” argued that “the problem is not bad people in healthcare – it is that good people are working in bad systems that need to be made safer.”

Peters says the systems still have a long way to go, 22 years later.

After the study, the association took note of high rates of catheter-related bloodstream infections in its ICUs. According to a 2006 study published in the New England Journal of Medicine, “an evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.”

Peters estimates thousands of lives have been saved since, as that lesson has been passed on to others. He sees a similar potential with implicit bias training, and believes it will teach medical professionals to listen better, and to treat their patients as individuals, responding to their unique needs.

“That’s why we use the term implicit or unintended bias,” he said. “I don't think anyone’s going out of their way to treat anyone differently or provide substandard care or to not listen to their concerns. I think what this training and this focus is all about is making sure that clinicians understand that you may desire to treat everyone the same, which is a laudable goal, but not everyone is coming to the clinical setting with the same set of circumstances in their day-to-day life.”

The hospital association recommends the implicit bias training offered through the Michigan Health Council to any organization that needs a program.

Peters acknowledged that the implicit bias training requirement is yet another demand on the time of medical professionals. In addition to working long hours, doctors and nurses have annual continuing education requirements. Workplaces may have additional requirements. And as of June 1, they face yet another state requirement for yet more training.

Peters thinks that the benefits of the new training requirement will outweigh the time commitment.

“Yes, we might require some time for our clinicians or employees to do this training,” Peters said. “But if we avoid rehospitalizations, if we avoid complications that require an extended hospital stay, we're going to save them time on the back end by having better outcomes.”

But Nobel argues the training is not a simple matter of professionals being trained to do better.

“This is the state interfering with people’s worldview,” Nobel said. “It has no business doing that. It has nothing to do with the quality of care. It has everything to do with politics.”

Over the last year, Nobel has shifted her efforts. Her work at Michigan Healthcare Freedom has become a job itself. But she’s still a nurse, and worries that requirements like implicit bias training will drain talent from the field, or keep it away.

“And who does that leave to take care of you?” Nobel asks.