Michigan Implicit Bias Training: Diversity Builder

health care team bias training Lara Michigan

The state of Michigan requires health care workers to participate in Implicit Bias training. Diversity Builder provides training that meets requirements and goes beyond compliance. Diversity Builder shares the benefits of such training including approaching health care with a different lens to reduce healthcare disparities, particularly among underrepresented identities. Diversity Builder offers the Michigan Lara training via online coaching with a live trainer, webinar, and onsite training. All sessions offer a certificate of completion.

LARA Bias Training Requirements in Michigan

With greater awareness of the widespread and devastating impact of inequity, it’s becoming more common for states and other government entities to require training on bias and discrimination. Since 2019, seven states have mandated training on implicit bias for some or all healthcare professions. Beginning on June 1, 2022, Michigan’s Department of Licensing and Regulatory Affairs (LARA) requires that healthcare professionals applying for license or registration complete at least two hours of implicit bias training. This includes all practitioners licensed under the state’s Public Health code except for those in veterinary medicine. It also requires that these same individuals applying for renewal complete one hour of implicit bias training for each year of their license or registration cycle.

What should be covered in the Michigan bias training?

The training is required to address the following topics:

Reducing barriers or disparities to the delivery of, and access to, health care services
Specific strategies to address disparities

Formal assessments to measure implicit bias in trainees, before and after the training, must be included. Furthermore, one or more of the following subjects must be covered:

Information on implicit bias, equitable access to health care, serving a diverse population, diversity and inclusion initiatives, and cultural sensitivity.
Strategies to remedy the negative impact of implicit bias by recognizing and understanding how it impacts perception, judgment, and actions that may result in inequitable decision making, failure to effectively communicate, and result in barriers and disparities in the access to and delivery of health care services.

The historical basis and present consequences of implicit biases based on an individual’s characteristics.

Discussion of current research on implicit bias in the access to and delivery of health care services.¹

Each of these topics will be addressed in-depth with hands-on activities, group discussions, and relevant exercises to assist healthcare professionals in understanding and dismantling their implicit bias.

^[1] Bureau of Professional Licensing. (2023, March 23). Public health code – general rules.

Inquire about Implicit Bias Training

List of Healthcare Professions Required to Take Michigan Implicit Bias Training

This unconscious bias training requirement applies to all practitioners licensed under the state’s Public Health code, including the following professions or fields:

Acupuncturists, chiropractors, massage therapists, and osteopaths
Athletic trainers, physical therapists, and occupational therapists
Counselors, Marriage & Family Therapists, psychologists, and behavior analysts
Dentists and optometrists
Genetic counselors
Midwives
Nurses and nursing home administrators
Medical specialists such as podiatrists, respiratory therapists, and audiologists
Pharmacists and pharmacy technicians
Physician’s Assistants
Sanitarians
Social Workers
Speech-Language Pathologists

License Renewals: These same individuals applying for renewal must also complete one hour of implicit bias training for each year of their license or registration cycle.

Why did Michigan introduce this new requirement for bias training for healthcare workers?

The Michigan Coronavirus Task Force on Racial Disparities was charged with examining healthcare disparities, with an emphasis on how COVID-19 impacted or worsened disparities affecting racial and ethnic minorities. The Task Force made a series of recommendations to mitigate these issues, among these implicit bias training for healthcare professionals.

“Implicit, unconscious bias exists within each of us, and as public servants we have a duty to understand and address how our biases can impact the lives of others. The health disparities highlighted during the pandemic made it clear that there is more work to do to ensure that bias does not prevent people of color from experiencing the same access to quality, equitable health care as everyone else.”²

This training ensures that those providing crucial health and therapeutic services will have the tools to serve diverse clients equitably.

Lara Requirements in Michigan

Where Can I Receive Implicit Bias Training, and What Documentation Do I Need?

Classes can be taught by nationally-recognized or state of Michigan-recognized health-related organizations, a state or federal agency, or organizations specializing in diversity, equity, and inclusion issues, among others. Both in-person and remote trainings are acceptable; in the case of synchronous (live) training, participants must interact with the instructor and other participants throughout the class. Asynchronous training such as a recorded webinar also qualifies under Michigan’s law. When applying for a license or registration, applicants should provide information about their implicit bias training, including the name of the program, date of the training, and the organization providing the training. The Department will audit a sample of applicants, who will need to supply documentation of their training.³

^[2] Governor Gretchen Whitmer and LARA Announce Adopted Training Requirement to Improve Equity Across Michigan’s Health Care System. (2021, June 1). Governer Gretchen Whitmer.
^[3] Bureau of Professional Licensing. (2023, March 23). Public health code – general rules.

What Is Implicit Bias?

While explicit biases are overt and can possibly be recognized more easily, implicit biases are unconscious and therefore difficult to recognize and address.⁴ But what is meant by implicit bias? According to the Bureau of Professional Licensing:

“Implicit bias” means an attitude or internalized stereotype that affects an individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic.⁵

An example of explicit bias would be a healthcare provider making the conscious decision to offer a different level of care to a specific demographic. With implicit bias, however, that provider would unintentionally offer different care, based on internalized ideas about the patient’s honesty, lifestyle, or other factors. In the latter case, the provider might not realize how their mindset is affecting their decisions or might deny that they have any bias. As will be discussed below, this leads to inferior health care and outcomes for patients, so it’s necessary for healthcare professionals to take action to address their own implicit bias.

This training will offer a live webinar with interactive elements as well as pre- and post-training assessments that fulfill the state’s training requirements and enable healthcare professionals to offer truly equitable, patient-centered care.

Healthcare Disparities and Bias

Research and information on historical and current healthcare disparities are listed as an important potential topic (as described by the state law), so this training will provide a detailed background on these subjects.

After the training, participants will understand the following:

The prevalence of implicit bias against marginalized populations in healthcare
How implicit bias results in disparities in healthcare, including low quality of care and poor communication between patients and providers
Marginalized patients facing inferior quality of care will sometimes seek alternative treatment or avoid healthcare altogether

Healthcare disparities for disadvantaged groups, when compared to privileged groups, are extremely well documented in the research literature. While there are multiple reasons for these disparities, many of them can be traced to implicit bias against racial, sexual, or gender minorities, disabled individuals, and other marginalized groups.

^[4] Sabin, J. (2022, July 14). Tackling implicit bias in health care.
^[5] Bureau of Professional Licensing. (2023, March 23). Public health code – general rules.

Landmark Bias Study on Health Care for Patients with Differing Ethnicities

An early landmark study on this case from the Institute of Medicine found that racial and ethnic patients received inferior health care than patients with identities in majorities because of implicit and explicit bias. These findings held true even when adjusted for differences such as income and health insurance.⁶ More recent studies have confirmed the widespread nature of implicit bias in medicine.

Bias Data Doctors Nurses and Quality of Care

For example, a 2017 systematic review (in which multiple studies are summarized or analyzed to draw on larger datasets) on implicit bias in medicine concluded that the vast majority of physicians and nurses have implicit bias on characteristics such as race/ethnicity, gender, age, socioeconomic status, and more.⁷ Of the research in this study, it was found that bias was present across the healthcare experience, including diagnosis, treatment, the number of questions asked of the patient, and the number of tests ordered. This trend has a negative effect on the patient-provider relationship and communication as well. Multiple studies have demonstrated that physicians with higher levels of implicit bias were more likely to dominate the conversation while meeting with Black patients, while Black patients felt less trust and confidence in these providers and rated the care they received as low quality.⁸

Bias Impacts on Marginalized Groups

Implicit bias has a serious negative impact on marginalized groups of all kinds. Disabled patients also face issues with implicit bias; a 2023 systematic review of forty-six previous studies found that most healthcare professionals have a moderate to strong negative implicit bias towards disabled patients.⁹ This also proves true for Lesbian, Bisexual, Gay, Transgender, or Queer (or LGBTQ) individuals. A study of 30 peer-reviewed papers on discrimination of LGBTQ patients in healthcare settings found evidence that personnel held negative attitudes towards this population, although this differed depending on the role and identity of the provider. This same study describes how these patients have been denied needed

^[6] DeAngelis, T. (2019, March). How does implicit bias by physicians affect patients’ health care?
^[7] FitzGerald, C., & Hurst, S. (2017, March 1). Implicit bias in healthcare professionals: a systematic review.
^[8] DeAngelis, T. (2019, March). How does implicit bias by physicians affect patients’ health care?
^[9] Antonopoulos, C., Sugden N., & Saliba A. (2023, April 20). Implicit bias toward people with disability: A systematic review and meta-analysis.

medicine, stigmatized based on their identity, or (in the case of transgender men) even faced verbal and physical abuse.¹⁰ As with other examples, this often resulted in patients choosing to delay or avoid seeking necessary healthcare. Implicit biases also extend to Latinx and American Indian individuals as well as people of size.¹¹ In other words, this troubling trend affects many vulnerable and marginalized populations seeking medical care in the United States.

The prevalence of implicit bias leading to disparities is true of more critical care as well as routine health care interactions. In fact, some research demonstrates that implicit bias is more likely to be a factor in high-stress conditions such as emergency medicine or critical care.¹² A 2016 study involving Black cancer patients concluded that practitioners with higher implicit bias spent less time with these patients and offered less support. In turn, the patients in this study had less confidence in their treatment plans, lower satisfaction and communication issues with their doctors.¹³ Yet another study, this one on giving birth in America, found that 20% of Black and Hispanic women had been mistreated based on their race, ethnicity, or language.¹⁴ This type of bias and substandard care sometimes leads to greater suspicion of healthcare providers and institutions, so that patients might choose alternative resources or avoid seeking medical help altogether.

Health Care Providers Bias in Communication

Some researchers suggest that implicit bias acts as a feedback cycle, in which providers’ preconceived notions about patients leads to less communication and care for the patient, who responds negatively to their provider. As a result, the patient has poorer outcomes, further reinforcing the providers’ bias towards that demographic. These negative dynamics can be reinforced when a provider and a patient are in under-resourced facilities or communities and when bias is exhibited by fellow providers.¹⁵ In other words, bias can be a product of one’s outlook, interpersonal interactions, and environment. Resolving implicit bias is therefore a matter of examining one’s own assumptions, speaking up against colleagues’ biased words and actions, and advocating for better working conditions in general.

In this section, research on the prevalence and effects of implicit bias and healthcare disparities was covered. After participants have a solid grounding on these topics, the training will move on to guidelines for an effective and constructive discussion on implicit bias.

^[10] Ayhan, C., Bilgin, H., et. al. (2019, November 4). A systematic review of the discrimination against sexual and gender minority in health care settings.
^[11] Wolsiefer, K., Mehl, M., et. al. (2021, June 16). Investigating the relationship between resident physician implicit bias and language use during a clinical encounter with Hispanic patients.
^[12] Saluja, B. & Bryant, Z. (2021, February 2). How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States.
^[13] DeAngelis, T. (2019, March). How does implicit bias by physicians affect patients’ health care?
^[14] Saluja, B. & Bryant, Z. (2021, February 2). How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States.
^[15] Vela, M., Eroundu, A., et. al. (2022, January 12). Eliminating explicit and implicit biases in health care: Evidence and research needs.

Best Practices for Effective Training on Implicit Bias

The Michigan law suggests various topics for the training under the umbrella of reducing disparities and barriers to healthcare. One of these is understanding how implicit bias is responsible for disparities as well as strategies for addressing these biases.

Strategies to remedy the negative impact of implicit bias by recognizing and understanding how it impacts perception, judgment, and actions that may result in inequitable decision making, failure to effectively communicate, and result in barriers and disparities in the access to and delivery of health care services.¹⁶

As such, the training will spend significant time on discussions and exercises to assist practitioners in understanding the role and dynamics of implicit bias in poor treatment, diagnosis, and overall experience of marginalized patients. It will also offer actionable techniques for providing equitable services to patients from disadvantaged or otherwise marginalized backgrounds.

Effective training on cultural sensitivity, racism, and related issues relies on creating a psychologically safe environment in which empathy and curiosity are emphasized and mistakes or questions are not penalized. This builds trust, allowing participants to connect with each other and the instructor while having honest conversations with less chance of defensiveness or embarrassment.¹⁷ Moreover, beginning with personal experiences and stories (for those willing to share) brings the group closer together while highlighting that marginalization is a concrete issue affecting many colleagues, not an abstract or academic concept.

Starting an implicit bias training with shared expectations for civility is also helpful. For example, participants should be encouraged to listen without interrupting, assuming good intent, and asking questions to understand others’ viewpoints. To foster a positive discussion, it’s also helpful for the facilitators to emphasize personal versus collective responsibility for racism and other forms of discrimination.

^[16] Bureau of Professional Licensing. (2023, March 23). Public health code – general rules.
^[17] Peek, M., Vela, M., et. al. (2020, December). Practical lessons for teaching about race and racism.

Regarding structural racism, instructors should stress that while we did not create these systems, it is important to acknowledge that we operate and sometimes benefit from these systems, and must all work to disrupt those systems that perpetuate racism.¹⁸

Healthcare professionals with substantial experience teaching about disparities in their field note that teaching about implicit bias can be fraught. Participants with more privilege can become defensive when asked to consider their own biases, making them less receptive to constructive discussions. Marginalized participants, on the other hand, sometimes feel as if they are stigmatized or asked to represent their community in these discussions.¹⁹ Because these crucial conversations can be difficult, it is important to handle these topics with sensitivity and nuance. For example, participants shouldn’t be pressured to share painful or embarrassing stories in the interests of building group understanding. If the discussion becomes contentious or heated, the facilitator should be ready to defuse the situation and remind participants of their shared expectations of civility and understanding. And participants with more privilege should be careful not to dominate the conversation while still fully engaging with the exercises and content.

Beginning the interactive portion of the training with shared expectations and the best practices noted above will facilitate the following discussion on reducing healthcare disparities and implicit bias.

Strategies for Reducing Healthcare Disparities

Awareness and self-reflection are key steps in working to dismantle an individual’s bias. The Harvard Implicit Association Test (or IAT) is widely used to measure implicit bias in healthcare and related fields, including in the majority of the studies referenced in this article.²⁰ The IAT is intended to highlight unconscious bias by determining whether an individual associates different groups of people (for example, older people) with a positive or negative evaluation, or with a stereotype.²¹ Test-takers are asked to sort different groups into categories and are rated based on how quickly they evaluate certain groups. For example, if a person is quicker to categorize a thin person as good, and a heavy person as bad, then they are scored as having an implicit bias towards thin people. These attitudes are rated along a spectrum as slight, medium or strong to measure the relative strength of bias. A wide variety of tests including ones focusing on BIPOC individuals, religious minorities, disabled individuals, and other groups, allow test-takers to identify and address implicit biases along multiple axes.

^[18] Peek, M., Vela, M., et. al. (2020, December). Practical lessons for teaching about race and racism.
^[19] Peek, M., Vela, M., et. al. (2020, December). Practical lessons for teaching about race and racism.
^[20] Saluja, B. & Bryant, Z. (2021, February 2). How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States.
^[21] About the IAT. (2011). Project Implicit.

As previously noted, because implicit bias is unconscious and sometimes even contradicts a person’s self-professed beliefs, it can be difficult to overcome these issues. Taking the IAT can reveal these biases, enabling a practitioner to consider how they might inadvertently treat certain demographics differently or using unfair assumptions. This training will include participant testing both before and after the class to offer quantitative information on implicit bias as well as concrete evidence of growth and learning.

Along with taking the IAT, there are specific steps that healthcare workers can take to lessen disparities from implicit bias. The language used by healthcare providers in patient descriptions or chart notes reflects and perpetuates implicit bias. Removing stigmatizing language and using neutral language instead can help address these issues.²² Best practices also encourage healthcare providers to individualize patients instead of treating those from specific communities as a monolith. For example, instead of asking certain demographics about adherence to a treatment plan, such as taking medication, they should ask all patients about their behavior.²³

Benefits of Empathy in Health Provider Communication

Empathetic communication strategies in order to establish positive provider-patient relationships are crucial. Much of the research cited above notes that poor communication or behavior on the part of healthcare professionals – for example, speaking in a condescending way, or downplaying patient concerns – leads to negative health outcomes and patient dissatisfaction. Practitioners who choose instead to cultivate strong relationships with their patients tend to view their patients as individuals, thus pushing back on their implicit bias.²⁴ Research also suggests that the word choices of physicians can affect patient satisfaction and adherence to treatment plans after a procedure. More specifically, physicians who used first-person plural pronouns (we, us), used positive emotion words more than negative emotion ones, focused more on the patient’s future, and shared ample information, had better outcomes than those who didn’t use these words or strategies.²⁵ In this training, the instructor will model positive communication strategies to assist participants in speaking more empathetically with patients. Participants will have the chance to reflect on their own approach to patient communication and to practice optimal strategies with other participants in guided exercises.

^[22] Sabin, J. (2022, July 14). Tackling implicit bias in health care.
^[23] DeAngelis, T. (2019, March). How does implicit bias by physicians affect patients’ health care?
^[24] Saluja, B. & Bryant, Z. (2021, February 2). How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States.
^[25] Wolsiefer, K., Mehl, M., et. al. (2021, June 16). Investigating the relationship between resident physician implicit bias and language use during a clinical encounter with Hispanic patients.

Top actions healthcare professionals can take to address implicit bias and improve patient outcomes:

Take the IAT, or a similar test of implicit bias. Reflect on the results and one’s own practices in patient interactions and care.
Normalize asking all patients about adherence, habits, etc. (instead of singling out certain demographics)
Foster good relationships by giving patients the time to talk and ask questions, speaking to them respectfully, using positive language, and taking their concerns seriously
Use neutral language when speaking about patients to other healthcare professionals or when making chart notes and documentation

While implicit bias is a damaging and widespread issue in healthcare, this training provides the background to understand the problem as well as actionable strategies to address issues. With provider self-awareness of implicit bias, along with a strong foundation in effective and affirming communication strategies for healthcare professionals and teams, organizations can significantly improve patient outcomes and satisfaction.

Michigan Implicit Bias Training