A black doctor speaks up against implicit bias training (required for all California MDs, including her)

February 23, 2023 • 10:00 am

We all know that data show implicit bias training doesn’t work, and could even be counterproductive by making blacks and whites more suspicious of each other. And yet there’s been no move to ditch implicit bias training; in fact, it seems to be spreading. As physician Marilyn SIngleton, a black doctor in California, reports, it’s required in California as part of “continuing education” for doctors—50 hours of implicit bias training—mostly involving race, but also gender, age, and disability—every two years. That’s a lot of hours for a method that doesn’t work! Its continuance and spread serve only to show that the organizations that mandate the training are doing something. But because the training is useless, this is purely a show of virtue.

You can read Singleton’s Washington Post op-ed by clicking on the screenshot below, and I found it archived here for free. I recommend reading the whole thing because it’s very good. (And it’s in the WaPo!)

Singleton is identified this way:

Marilyn Singleton is a board-certified anesthesiologist and a visiting fellow at the medical advocacy organization Do No Harm.

She’s also pretty courageous, because I can imagine the social-media opprobrium, not to mention ostracism among her fellow doctors, for speaking the truth:

A few quotes, but really, I’d like to quote the whole thing:

When I graduated with a medical degree in 1973, a Black woman in a class of mostly White men, there was a real sense that the days of obsessing over skin color and making race-based assumptions about our fellow human beings was finally fading — and, hopefully, soon gone for good.

Apparently not. That racial obsession has come rushing back — in academia, politics, business and even in my beloved medical profession. But now it’s coming from the opposite direction. The malignant false assumption that Black people are inherently inferior intellectually has been traded in for the malignant false assumption that White people are inherently racist.

That is the basic message conveyed by “implicit bias training,” which is now mandatory for California physicians; it is a message that I believe is harmful both to physicians and patients. There is a sad irony in all this, because the misguided focus on racism is intended to improve the health and well-being of Black patients in particular.

. . . In California, where I’ve been licensed since 1974, every physician is required by law to participate in this racially regressive practice. Doctors must take implicit bias training not just once but as part of the curriculum of “continuing medical education,” for at least 50 hours every two years, required for their medical license renewal.

The training’s focus is on exactly what the name suggests: Deeply ingrained prejudice toward people of different races. There is no room for debate, for the law states baldly: “Implicit bias, meaning the attitudes or internalized stereotypes that affect our perceptions, actions, and decisions in an unconscious manner, exists.”

And the law asserts as fact that implicit bias is responsible for “racial and ethnic disparities in health care,” particularly for Black women.

JAC note added later: It’s not clear exactly how many hours of the continuing education is devoted to implicit bias training, as one reader points out below. However, more than one hour is too much. I’ve been to a class on implicit bias at the U of C, and have also taken implicit bias tests (I was diagnosed as “not biased,” but I can see how easy it would be to game those tests.) I found the class patronizing and almost insulting when they asked us to tell stories about how we may have manifested implicit bias.

Here’s part of what that law says: flat assertions with no evidence to back them up (bolding is mine)

Section 1. 

The Legislature finds and declares all of the following:

  • Implicit bias, meaning the attitudes or internalized stereotypes that affect our perceptions, actions, and decisions in an unconscious manner, exists, and often contributes to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics.
  • Implicit bias contributes to health disparities by affecting the behavior of physicians and surgeons, nurses, physician assistants, and other healing arts licensees.
  • Evidence of racial and ethnic disparities in health care is remarkably consistent across a range of illnesses and health care services. Racial and ethnic disparities remain even after adjusting for socioeconomic differences, insurance status, and other factors influencing access to health care.
  • African American women are three to four times more likely than white women to die from pregnancy-related causes nationwide. African American patients often are prescribed less pain medication than white patients who present the same complaints, and African American patients with signs of heart problems are not referred for advanced cardiovascular procedures as often as white patients with the same symptoms.
  • Implicit gender bias also impacts treatment decisions and outcomes. Women are less likely to survive a heart attack when they are treated by a male physician and surgeon. LGBTQ and gender-nonconforming patients are less likely to seek timely medical care because they experience disrespect and discrimination from health care staff, with one out of five transgender patients nationwide reporting that they were outright denied medical care due to bias.

More from Dr. Singleton:

. . . I reject the unscientific accusation that people are defined by their race, not by their individual beliefs and choices. It is little consolation that studies are finding implicit bias training has no effect on its intended targets, and might even make matters worse.

Think about the message this mandate sends to Black physicians. It suggests that I should be wary of my White colleagues because, after all, they’re biased against people like me. Sure, they can undergo frequent training, but their bias is always going to be there, beneath the surface, threatening to rear its ugly, racist head. Collegiality and collaboration — two essential components of high-quality medical care — are targeted by this mandate. Call that an implicit bias.

Since I became a physician, I have seen exactly one instance of racism in health care — and it was from a patient, not a fellow physician. As for my colleagues, I have been consistently impressed with the conscientious, individualized care they have provided to patients of every race and culture. When we all took our oath to “first, do no harm,” we meant it, and we live it. I can’t imagine spending my entire career thinking my peers can’t uphold that oath without constant racial reeducation.

Now of course you can dismiss Singleton’s claims because they are her “lived experience”, but you could just as well dismiss the claims of all the medical schools and the proclamations by medical associations that the whole profession is rife with systemic racism. In fact, at least Singleton has some evidence or her claims, but med schools and medical associations have only the “evidence” that there are disproportionately few black doctors compared to their proportion in the general population. But as we know, inequity is not prima facie evidence for racism—systemic or otherwise.

Singleton notes that black patients get an even worse message, which is that white doctors could hurt their health. And that message is injurious to the health of black people.

She finishes her piece this way:

The whole point of implicit bias training is to create better health outcomes for Black patients and others who might be the target of discrimination, but the opposite seems more likely. It fosters a climate of distrust and resentment that threatens to undermine the medical and moral progress I’ve seen over the decades. When I graduated from medical school, we were moving past the era of racial obsession and anger. Why are we going back to the days when race defined so many lives and dimmed so many futures?

If you want to see evidence compiled by Lee Jussim that the concept of implicit bias is flawed and that training to eliminate it is useless, go here or see the video here.

Here are the three steps that are skipped when organizations mandate implicit bias training:

a.) Ascertaining that inequities are the result of racism

b.) Assuming that the racism is expressed unconsciously, via “implicit bias”

c.) Assuming that implicit bias training actually works in eliminating racist attitudes

All three assumptions have no evidence behind them, ergo implicit bias training is unscientific. As ever, I’m not denying that some white people in the medical establishment are racist. I’m raising doubts, as does Dr. Singleton, that the medical establishment itself has inbuilt racism, and it is that which not only leads to inequities among physicians, but also harms healthcare for minorities.


Singleton, from her Linked In page:

h/t: Tm

25 thoughts on “A black doctor speaks up against implicit bias training (required for all California MDs, including her)

  1. The “racial obsession” has indeed “come rushing back”, nor does there exist any reason to think that it is abating; in fact, the racializing of everything (mandated “equity” in all federal agencies and DEI “loyalty oaths” in many universities, to name but two) is proceeding apace, with rational opposition to this malignancy metastasizing throughout the culture often stigmatized as being somehow “racist”.

    1. You do know that Dr. King’s “dream” was indeed aspirational, somewhere over the horizon in Shangri-La. In the meantime he very much advocated for explicit race preference in education and hiring to bring the Negro up to parity with the white man, after which we could then start talking about character. You just have to read his excuse-laden 1965 interview with Alex Haley (published unsigned) in Playboy.

      I don’t think he would have gone for this implicit bias in medicine stuff either though. He wanted more black people in medical school, and everywhere else. Period.

  2. I suspect that the numbers in this article are off, that a *total* of 50 hours of continuing medical education is required every two years, of which some much smaller portion is “implicit bias” training. In any event, California lawyers are required to do 1 hour of this every three years (out of 25 hours total). The idea of “implicit bias” is quasi-Freudian, it’s that you’ve got some deeply-buried prejudices. This is no doubt true, but listening to a lecture for an hour isn’t going to cure that. These lectures amount to no more than the common-sense admonition to “try to not be a dick”. Don’t ask your black colleagues to recommend a good fried chicken restaurant, that sort of thing (no, I’m not making this up). Given how most lawyers act, telling them once every three years to not act like assholes is probably warranted. Of course, the notion of “implicit bias” has been a gift to the plaintiff’s bar and comes in handy in that context. And it has, often enough, soured intra-office relations, for the same reason.

    1. It’s not clear how much of that 50 hours is due to implicit bias training (I do know that doctors do need a lot of continuing education), so I’ll add a note in the text to that effect. I know that I, for example, would resent having to take ANY implicit bias training (I did go to a diversity class on that just to educate myself), but the U of C would never require anything like that. I took implicit bias tests, too, and found myself unbiased, but I saw how flawed theywere.

      1. I’m surprised that the U of C doesn’t require it, as a matter of course, for its administrative employees (if not for the academics). Any sizable employer who doesn’t require DEI training is running a risk. This stuff is dumb, it doesn’t do anything, it’s a waste of time, it may even be counter-productive, but when (not if) you get sued, you need to be able to point to having done it.

  3. Implicit bias training creates good, high paying, American jobs. This is what you get when you ignore costs and benefits. DEI creates lots of employment at Universities so that is why we get so much DEI.

    1. Yes. It’s elite job creation for the chattering classes, a regressive social policy that in true Orwellian fashion pretends it has something to do with social justice.

    2. Remembering the Hitchens story about the watcher at the gate of the ghetto, paid to keep an eye out for the messiah. “It’s steady work.”

  4. The wave of DEI orthodoxy inundating medical schools involves not only curriculum and training of physicans, but also the very definition of research. At UCSF, recommendations have been issued by a “Task Force on Equity and Anti-Racism in Research”, including the recommendation that a vice-chancellor for DEI in research be appointed. With this, our academic DEI movement has evolved into full-bore Lysenkoism. See:

  5. I loved her article, but almost every single response from WaPo readers was a ghastly condemnation of Dr. Singleton for obviously needing the mandatory training.

    1. Maybe the WaPo commentariat—they are a strange bunch, I know, I used to subscribe—think she is of mixed race and assume it’s her white racist side talking. Or she has internalized white racism from her decades in practice and can’t be trusted for that reason, either.

  6. I understand how the Implicit Bias concept and the so-called test has been thoroughly refuted. Im curious though what to make of the fact that — for instance — newborn black infants do better when under the care of black physicians than that of white?

    A large body of work highlights disparities in survival rates across Black and White newborns during childbirth. We posit that these differences may be ameliorated by racial concordance between the physician and newborn patient. Findings suggest that when Black newborns are cared for by Black physicians, the mortality penalty they suffer, as compared with White infants, is halved.


    1. Frank, that link only takes me to the title page of the current issue and the search for past articles—the relevant one is from 2020–doesn’t work for me. From news stories about it, it appears to be a study pulled from a large administrative database. The study author, who is black, has lots of CRT-based hypotheses about why black babies survived better with black doctors but none can be tested in this type of study. Admin databases don’t have enough information captured from each clinical encounter to control for things like whether black doctors were GPs delivering uncomplicated low-risk pregnancies and the white doctors were board-certified specialists in high-risk pregnancy centres where outcomes are sometimes disappointing despite expert culturally safe care. If I can recover the study I will certainly read it.

      Studies like this are good for the CVs of black medical activists but they have the consequence, unintended no doubt, of motivating white and white-adjacent doctors to have as little to do with black patients as possible, especially in fraught, high-anxiety specialties like obstetrics. You’re guilty of clinically important implicit bias that will kill a baby as soon as the patient lays eyes on you. Of course they don’t trust you. If anything goes wrong, you’re as good as convicted.

      (Jerry, there is no hypertext for “here” in your reply. I would be interested in reading it given that we talked about that Ontario study that found worse outcomes when male surgeons operated on female patients. That was from a prospectively constructed surgical atlas with much more detail about patients and surgeons than in the usual admin database.)

  7. One could add a fourth step to the above 3 usually-skipped steps:

    (d) Ascertaining that, if people do have implicit bias, it then affects their real-life decision making.

    The Harvard IAT test is based on unconscious judgments made in a fraction of a second. It’s likely that real-life decisions involve much more consideration and deliberation, likely using different brain circuitry. Thus one can’t just assume that bias assessed by the IAT has real-life consequences.

  8. Dr. Singleton’s article is sane and rational. Is it really helpful for the law to hold that racism is the default state and that even those who have never evidenced racism in their lives are racist nonetheless, albeit implicitly? I don’t think so.

    Even as racism recedes in actual practice, it’s reanimated in the form of “implicit” racism. It seems to me that those opposed to racism don’t really want it to go away. It‘s a major source of profit for the diversity training consultants and a major source of material for social activists. Sad. People of truly good will want racism to go away; they don’t want to keep it alive for their own benefit.

  9. How about. Occasional biases? e.g. where it is tiredness not racism you are displaying. The woman looked like your mother- in- law from hell AND your tired. Oh my, it’s tempting to prescribe something that will loosen the bowls… she thinks.
    It’s as real as racism and probably no more prevalent in the medical profession than any other work environment. I find it hard to believe that any doctor would not want a less than optimum result for a patient. No doctor wants a trail of ailing sick they have failed linked to their name. There will be exceptions.
    In my readings and if true, NOISE is more of a REAL problem. That is, disparate diagnoses with cases of equivalence. Discrepancies in judgement calls, not racism is where the need is to focus and everyone would be far better off for it.
    Barking up the wrong tree wasting time, wealth, on a perceived fault of a system does not help the infirm, nor does it need a psychological pathogen like DEI or IBT!

  10. I wonder how many hours of continuing education is by law required of California state legislators, and what portion of that is implicit bias training.

  11. Devotees of the Implicit Association Test and its uses could gain some perspective from
    Cotton Mather’s celebrated tome Wonders of the Invisible World: Being an Account of the Tryals of Several Witches Lately Executed in New England (1693). In it, the Reverend Mather advises that spectral evidence should be admissible, but that it is best accompanied by other evidence of a less spectral type.

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