California’s implicit-bias training mandate erodes patient-doctor bond and the Constitution

Dr. Azadeh Khatibi is a devoted ophthalmologist in Los Angeles, but her care for people involves much more than meets the eye. “I was born in Iran when we had the Iranian Revolution and the government was telling people what to do and what to say,” she recalls. “I thought that was all behind me, but now I know better.”

As a child, Azadeh and her family immigrated from Tehran to California. She excelled in school, earning two master’s degrees and a joint medical degree from the Universities of California San Francisco and Berkeley. Dr. Khatibi’s career flourished; she eagerly shared her expertise in her own practice and in California’s continuing medical education (CME) courses, never expecting the government would ever stir the echoes of life in Iran.

Then came AB 241, a mandate that every CME course must include implicit- bias training. Enacted under the guise of healthcare equity, the mandate is chilling; it dictates how CME instructors must speak and act, all at the expense of patient care, medical morality, and free speech.

Implicit-bias training springs from the controversial idea that medical professionals unconsciously treat patients differently based on immutable characteristics such as race and gender and, therefore, must be aware of their own biases.

Evidence is mixed that implicit bias even exists, much less that it is rampant throughout the medical industry, as proponents of the training assert. In fact, clearer evidence shows that improper implicit-bias training can actually backfire, triggering anger, frustration, and resentment among healthcare providers. Forcing issues of race and other immutable characteristics into the patient-doctor relationship—instead of focusing on medical considerations—encourages distrust and risks undermining that relationship.

Nevertheless, in their clamor to address perceived disparities in healthcare, California legislators passed AB 241 in 2019, requiring all CME courses that deal with direct patient care carve out time for discussion of implicit bias—regardless of the instructor, the subject, or the relevance.

CME courses covering interventional radiology, advanced endoscopic techniques, or aneurysm repair, for example, must set aside time in each session to remind participants to be conscious of a patient’s race, ethnicity, gender, and sexual orientation.

There’s no opting out, either. Every California physician, physician assistant, and nurse must log 50 CME hours every two years for license renewal.

CME instructors, meanwhile, must squeeze the controversial topic into their courses whether or not it’s pertinent to their medical courses. Nor do their own viewpoints matter. The mandate forces them to endorse ideas they may find unconvincing or unproven—and may otherwise reject—that implicit bias infects all healthcare providers.

Medical care should be based on each patient’s individual situation and condition. California’s implicit-bias training mandate does the exact opposite. It implants the notion that subconscious, unintentional feelings and thoughts are just as important as reasoned medical judgment and instructs doctors to prioritize characteristics like race when caring for their patients.

As an experienced CME organizer and instructor herself, Dr. Khatibi must now replace a block of teaching time in her areas of medical expertise with implicit- bias training. To her, the law smacks of the speech restrictions in her childhood Iran and threatens the core principles of medicine.

“For the government to tell doctors what they can and cannot teach to other doctors is really frightening to me,” she warns. “Not saying what you would have taught because you are forced by law to teach something else changes both medical education and the practice of medicine. The state should not be involved in what is taught and not taught in medicine.”

Mandatory implicit-bias training defies common sense and medical ethics; it is also unconstitutional. Forcing physician educators to espouse and promote the government’s favored viewpoints flagrantly violates the First Amendment’s free speech guarantee.

“CME instructors do not need California legislators telling them what to teach physicians or how to teach them,” explains PLF attorney Caleb Trotter. “Government interference in the sharing of knowledge and expertise between CME instructors and physicians by forcing implicit-bias training is chilling, dangerous, and illegal.”

“When the government is telling people what to do and putting limits on their speech, there is a specter of fear,” says Dr. Khatibi. “I know how dangerous that is because I saw it in Iran.”

If there’s one thing Iran’s theocratic, authoritarian regime reinforced for Dr. Khatibi, however, it’s that liberty is worth pursuing and, once achieved, must be protected. It’s a conviction she was practically born with—her first name literally means “freedom.”

“All of the Azadehs I meet tend to be very much like me, very spirited, very concerned about what’s right and wrong, and doing the right thing,” she smiles. “I have to be a force for good. Most doctors I know believe what’s happening with free speech is ridiculous, but they’re afraid to say anything, or they’re getting burned out and leaving medicine.” Represented at no charge by PLF, Dr. Khatibi is suing to restore free speech in medicine and to prevent the mandate from spreading to other states.

“I can’t imagine not going to work every day and helping someone,” declares Dr. Khatibi. “Now the government is dictating how I help people, with a law that is backed by very little evidence and is unconstitutional. I have to fight it.”