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Black mothers in Virginia have worse health outcomes. Advocates want bias training for doctors, but can it narrow the gap?

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Birthing

Tiffany Casby cradles her newborn son Zayne, shortly after birthing him at Embrace Midwifery & Birth Center in Richmond in 2017. 

Like many health experts, Dora Muhammad was dismayed when national headlines began to highlight growing racial disparities in maternal mortality.

Virginia was no exception. Black women in the state are more than twice as likely to die in childbirth than White women, according to the most recently available data from the state Department of Health. But Muhammed, the health equity program manager for the nonprofit Virginia Interfaith Center, was even more concerned about why.

“It’s already well-known that the rates are higher,” she said. Not as familiar was a 2019 report from the Virginia Maternal Mortality Review team, which analyzed the role of chronic illnesses in pregnancy-related deaths. Among women with long-term conditions, Black women died at more than double the rate as white patients. But 44% of all deaths, researchers found, were linked to at least one provider-related failure, including “a lack of diagnosis, treatment or follow-up.”

“The most common thread I hear is that a Black woman will come in with pain, with a condition where she knows something is wrong with her body,” said Muhammed, who worked with the governor’s office to coordinate a series of listening sessions across the state. “And instead, she’s just not taken seriously by her doctor.”

Those experiences have informed a growing push to require implicit bias training for Virginia’s medical professionals. The concept isn’t new for the state’s General Assembly, which recently passed a similar law requiring teachers to be assessed on “cultural competency.”

While the trainings sometimes go by different names, the underlying concept is similar, Muhammad said. The idea is that poor outcomes, whether in education or health, can be linked to unconscious differences in how people of color are treated. But if providers learn to recognize and counteract those biases, treatment could improve. Other states, including Michigan and California, have passed similar laws aimed at ending discrimination in doctor’s offices.

“It’s a training to undo that level of thinking that comes with seeing race,” Muhammad said. “Like, when you hear the exact same thing coming from a Black woman that you hear coming from a white woman, why is the response different?”

It’s an approach the Virginia Board of Medicine also tentatively endorsed at a Thursday meeting. Currently, members don’t have the authority to mandate new training for licensees (the Board of Pharmacy is the only regulatory board with that ability under state law). But after submitting the proposal in April, Muhammad hoped members would back legislation to require implicit bias education for licensed providers across the state.

Support for a mandate, though, wasn’t universal. Some doctors have been divided by a 2016 law requiring two hours of continuing education on opioids every two years. For those opposed, there’s often resistance to the idea of lawmakers inserting themselves into medicine — and to mandating training that might not be relevant for all providers.

“Education does not, I don’t think, tend to impact what we have as an already inherent bias,” said Dr. David Archer, the board’s vice president. “And when you say, ‘You have to do that’ to doctors, you tend to get some pushback.”

Right now, there’s no clear evidence on whether continuing education has been effective at improving patient outcomes. While multiple studies have confirmed that many medical professionals do hold implicit biases — and that those biases affect the quality of care — there’s little conclusive research showing whether bias training is actually effective. The board also hasn’t assessed whether the current opioid education has reduced improper prescribing.

But given how extensively discrimination can affect patient care, many members were supportive of the requirement.

“In this particular case, the bias impacts such a large percent of Virginians that I think this is a special issue,” said Dr. Joel Silverman, a psychiatrist representing Richmond. “I am not in favor of having 15 different training requirements, but I think this one is relevant to a whole host of different issues.”

While the board didn’t submit or endorse legislation that would specifically mandate implicit bias training, it did take two concrete steps. First, the members voted to recommend the training — and send out a list of available courses — to licensees across the state. The board’s executive director, Dr. William Harp, also clarified that the training would count toward relicensure, which requires 60 hours of continuing medical education per two-year renewal cycle.

Additionally, members voted to request legislation that would grant them the authority to mandate new training for licensees — similar to existing statutes governing the Board of Pharmacy. President Blanton Marchese, one of the board’s citizen members, said it would allow them to require up to two two-hour courses in whatever medical subject matters they deemed relevant.

“So when something like this comes up, we would have the authority to say, ‘Right here, today, everyone needs those two hours to keep their license,’” he said.

Muhammad supported the measure, but said the Interfaith Center still plans to submit a bill that would specifically require implicit bias training.

“It has to be mandated,” she said. “Because a lot of people don’t think they hold these biases. And then they won’t bother taking it because they think it doesn’t apply to them.”

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