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California effort to confront implicit bias among doctors faces 1st Amendment challenge

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California effort to confront implicit bias among doctors faces 1st Amendment challenge

Los Angeles anesthesiologist Dr. Marilyn Singleton was outraged about a California requirement that every continuing medical education course include training in implicit bias — the ways in which physicians’ unconscious attitudes might contribute to racial and ethnic disparities in healthcare.

Singleton, who is Black and has practiced for 50 years, sees calling doctors out for implicit bias as divisive, and argues that the state cannot legally require her to teach the idea in her continuing education classes. She has sued the Medical Board of California, asserting a constitutional right not to teach something she doesn’t believe.

The way to address healthcare disparities is to target low-income people for better access to care, rather than “shaking your finger” at white doctors and crying “racist,” she said. “I find it an insult to my colleagues to imply that they won’t be a good doctor if a racially divergent patient is in front of them.”

The litigation is part of a national crusade by right-leaning advocacy and legal groups against diversity, equity and inclusion, or DEI, initiatives in healthcare. The resistance is inspired in part by last year’s U.S. Supreme Court ruling barring affirmative action in higher education.

The California lawsuit does not dispute the state’s authority to require implicit-bias training. It questions only whether the state can require all teachers to discuss implicit bias in their continuing medical education courses. The suit’s outcome, however, could influence obligatory implicit-bias training for all licensed professionals.

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Leading the charge is the Pacific Legal Foundation, a Sacramento-based organization that describes itself as a “national public interest law firm that defends Americans from government overreach and abuse.” Its clients include the activist group Do No Harm, founded in 2022 to fight affirmative action in medicine. The two groups have also joined forces to sue the Louisiana medical board and the Tennessee podiatry board for reserving board seats exclusively for racial minorities.

In their complaint against the California Medical Board, Singleton and Do No Harm, along with Los Angeles ophthalmologist Dr. Azadeh Khatibi, argue that the implicit-bias training requirement violates the 1st Amendment rights of doctors who teach continuing medical education courses by requiring them to discuss how unconscious bias based on race, ethnicity, gender identity, sexual orientation, age, socioeconomic status or disability can alter treatment.

“It’s the government saying doctors must say things, and that’s not what our free nation stands for,” said Khatibi, who immigrated to the U.S. from Iran as a child. Unlike Singleton, Khatibi does believe implicit bias can unintentionally result in substandard care. But, she said, “on principle, I don’t believe in the government compelling speech.”

The lawsuit challenges the evidence of implicit bias in healthcare, saying there is no proof that efforts to reduce bias are effective. Interventions have thus far not demonstrated lasting effects, studies have found.

In December, U.S. District Judge Dale S. Fischer dismissed the suit but allowed the Pacific Legal Foundation to file an amended complaint. A hearing is scheduled for March 11 in federal court in Los Angeles.

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In enacting the training requirement, the California Legislature found that physicians’ biased attitudes unconsciously contribute to healthcare disparities. It also found that racial and ethnic disparities in healthcare outcomes are “remarkably consistent” across a range of illnesses and persist even after adjusting for socioeconomic differences, whether patients are insured and other factors influencing care.

Black women are three to four times as likely as white women to die of pregnancy-related causes, are often prescribed less pain medication than white patients with the same complaints, and are referred less frequently for advanced cardiovascular procedures, the Legislature found.

It also noted that women treated by female doctors were more likely to survive heart attacks than those treated by men. This month, the Legislature’s Black Caucus unveiled a bill requiring implicit-bias training for all maternal care providers in the state.

Dr. Khama Ennis, who teaches an implicit-bias class for Massachusetts doctors, sees only the best intentions in her fellow physicians. “But we’re also human,” she said in an interview. “And to not acknowledge that we are just as susceptible to bias as anybody else in any other field is unfair to patients.”

Ennis offered an example of her own bias in a training session. Preparing to treat a patient in a hospital emergency room, she noticed a Confederate flag tattoo on his forearm.

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“As a Black woman, I had to have a quick chat with myself,” she said. “I needed to ensure that I provided the same standard of care for him that I would for anyone else.”

Ennis’ class meets the requirements of a Massachusetts law that physicians earn two hours of instruction in implicit bias to obtain or renew their licenses, as of 2022.

That same year, California began requiring that all accredited continuing medical education courses involving direct patient care include discussion of implicit bias. The state mandates 50 hours of continuing education every two years for doctors to maintain their licenses. Private institutions offer courses on an array of topics, and physicians generally teach them.

Teachers may tell students they do not believe implicit bias drives healthcare disparities, Fischer wrote in her December ruling. But the state, which licenses doctors, has the right to decide what must be included in the classes, the judge wrote.

Professionals who elect to teach courses “must communicate the information that the legislature requires medical practitioners to have,” the judge wrote. “When they do so, they do not speak for themselves, but for the state.”

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Whether they speak for themselves or for the state is a pivotal question. While the 1st Amendment protects private citizens’ right to free speech, that protection does not extend to government speech. The content of public school curricula, for example, is the speech of state government, not the speech of teachers, parents or students, courts have said.

The Pacific Legal Foundation’s amended complaint aims to convince the judge that its clients teach as private citizens with 1st Amendment rights. If the judge again rules otherwise, lead attorney Caleb Trotter said, he plans to appeal the decision to the U.S. Court of Appeals for the 9th Circuit, and, if necessary, the Supreme Court.

“This is not government speech at all,” he said. “It’s private speech, and the 1st Amendment should apply.”

“Plaintiffs are plainly wrong,” lawyers for Rob Bonta, the state attorney general, responded in court papers. “There can be no dispute that the State shapes or controls the content of continuing medical education courses.”

The medical board declined to comment on the pending litigation.

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From 2019 through July 2022, in addition to California and Massachusetts, four states enacted legislation requiring healthcare providers to be trained in implicit bias.

A landmark 2003 Institute of Medicine report, “Unequal Treatment,” found that limited access to care and other socioeconomic differences explain only part of racial and ethnic disparities in treatment outcomes. The expert panel concluded that clinicians’ prejudices could also contribute.

In the two decades since the report’s release, studies have documented that bias does influence clinical care and contribute to racial disparities, a 2022 report said.

But implicit-bias training might have no impact and might even worsen discriminatory care, the report found.

“There’s not really evidence that it works,” Khatibi said. “To me, addressing healthcare disparities is really important because lives are at stake. The question is, how do you want to achieve these ends?”

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KFF Health News, formerly known as Kaiser Health News, is a national newsroom that produces in-depth journalism about health issues.

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Diablo Canyon clears last California permit hurdle to keep running

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Diablo Canyon clears last California permit hurdle to keep running

Central Coast Water authorities approved waste discharge permits for Diablo Canyon nuclear plant Thursday, making it nearly certain it will remain running through 2030, and potentially through 2045.

The Pacific Gas & Electric-owned plant was originally supposed to shut down in 2025, but lawmakers extended that deadline by five years in 2022, fearing power shortages if a plant that provides about 9 percent the state’s electricity were to shut off.

In December, Diablo Canyon received a key permit from the California Coastal Commission through an agreement that involved PG&E giving up about 12,000 acres of nearby land for conservation in exchange for the loss of marine life caused by the plant’s operations.

Today’s 6-0 vote by the Central Coast Regional Water Board approved PG&E’s plans to limit discharges of pollutants into the water and continue to run its “once-through cooling system.” The cooling technology flushes ocean water through the plant to absorb heat and discharges it, killing what the Coastal Commission estimated to be two billion fish each year.

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The board also granted the plant a certification under the Clean Water Act, the last state regulatory hurdle the facility needed to clear before the federal Nuclear Regulatory Commission (NRC) is allowed to renew its permit through 2045.

The new regional water board permit made several changes since the last one was issued in 1990. One was a first-time limit on the chemical tributyltin-10, a toxic, internationally-banned compound added to paint to prevent organisms from growing on ship hulls.

Additional changes stemmed from a 2025 Supreme Court ruling that said if pollutant permits like this one impose specific water quality requirements, they must also specify how to meet them.

The plant’s biggest water quality impact is the heated water it discharges into the ocean, and that part of the permit remains unchanged. Radioactive waste from the plant is regulated not by the state but by the NRC.

California state law only allows the plant to remain open to 2030, but some lawmakers and regulators have already expressed interest in another extension given growing electricity demand and the plant’s role in providing carbon-free power to the grid.

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Some board members raised concerns about granting a certification that would allow the NRC to reauthorize the plant’s permits through 2045.

“There’s every reason to think the California entities responsible for making the decision about continuing operation, namely the California [Independent System Operator] and the Energy Commission, all of them are sort of leaning toward continuing to operate this facility,” said boardmember Dominic Roques. “I’d like us to be consistent with state law at least, and imply that we are consistent with ending operation at five years.”

Other board members noted that regulators could revisit the permits in five years or sooner if state and federal laws changes, and the board ultimately approved the permit.

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Deadly bird flu found in California elephant seals for the first time

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Deadly bird flu found in California elephant seals for the first time

The H5N1 bird flu virus that devastated South American elephant seal populations has been confirmed in seals at California’s Año Nuevo State Park, researchers from UC Davis and UC Santa Cruz announced Wednesday.

The virus has ravaged wild, commercial and domestic animals across the globe and was found last week in seven weaned pups. The confirmation came from the U.S. Department of Agriculture’s National Veterinary Services Laboratory in Ames, Iowa.

“This is exceptionally rapid detection of an outbreak in free-ranging marine mammals,” said Professor Christine Johnson, director of the Institute for Pandemic Insights at UC Davis’ Weill School of Veterinary Medicine. “We have most likely identified the very first cases here because of coordinated teams that have been on high alert with active surveillance for this disease for some time.”

Since last week, when researchers began noticing neurological and respoiratory signs of the disease in some animals, 30 seals have died, said Roxanne Beltran, a professor of ecology and evolutionary biology at UC Santa Cruz. Twenty-nine were weaned pups and the other was an adult male. The team has so far confirmed the virus in only seven of the dead pups.

Infected animals often have tremors convulsions, seizures and muscle weakness, Johnson said.

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Beltran said teams from UC Santa Cruz, UC Davis and California State Parks monitor the animals 260 days of the year, “including every day from December 15 to March 1” when the animals typically come ashore to breed, give birth and nurse.

The concerning behavior and deaths were first noticed Feb. 19.

“This is one of the most well-studied elephant seal colonies on the planet,” she said. “We know the seals so well that it’s very obvious to us when something is abnormal. And so my team was out that morning and we observed abnormal behaviors in seals and increased mortality that we had not seen the day before in those exact same locations. So we were very confident that we caught the beginning of this outbreak.”

In late 2022, the virus decimated southern elephant seal populations in South America and several sub-Antarctic Islands. At some colonies in Argentina, 97% of pups died, while on South Georgia Island, researchers reported a 47% decline in breeding females between 2022 and 2024. Researchers believe tens of thousands of animals died.

More than 30,000 sea lions in Peru and Chile died between 2022 and 2024. In Argentina, roughly 1,300 sea lions and fur seals perished.

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At the time, researchers were not sure why northern Pacific populations were not infected, but suspected previous or milder strains of the virus conferred some immunity.

The virus is better known in the U.S. for sweeping through the nation’s dairy herds, where it infected dozens of dairy workers, millions of cows and thousands of wild, feral and domestic mammals. It’s also been found in wild birds and killed millions of commercial chickens, geese and ducks.

Two Americans have died from the virus since 2024, and 71 have been infected. The vast majority were dairy or commercial poultry workers. One death was that of a Louisiana man who had underlying conditions and was believed to have been exposed via backyard poultry or wild birds.

Scientists at UC Santa Cruz and UC Davis increased their surveillance of the elephant seals in Año Nuevo in recent years. The catastrophic effect of the disease prompted worry that it would spread to California elephant seals, said Beltran, whose lab leads UC Santa Cruz’s northern elephant seal research program at Año Nuevo.

Johnson, the UC Davis researcher, said the team has been working with stranding networks across the Pacific region for several years — sampling the tissue of birds, elephant seals and other marine mammals. They have not seen the virus in other California marine mammals. Two previous outbreaks of bird flu in U.S. marine mammals occurred in Maine in 2022 and Washington in 2023, affecting gray and harbor seals.

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The virus in the animals has not yet been fully sequenced, so it’s unclear how the animals were exposed.

“We think the transmission is actually from dead and dying sea birds” living among the sea lions, Johnson said. “But we’ll certainly be investigating if there’s any mammal-to-mammal transmission.”

Genetic sequencing from southern elephant seal populations in Argentina suggested that version of the virus had acquired mutations that allowed it to pass between mammals.

The H5N1 virus was first detected in geese in China in 1996. Since then it has spread across the globe, reaching North America in 2021. The only continent where it has not been detected is Oceania.

Año Nuevo State Park, just north of Santa Cruz, is home to a colony of some 5,000 elephant seals during the winter breeding season. About 1,350 seals were on the beach when the outbreak began. Other large California colonies are located at Piedras Blancas and Point Reyes National Sea Shore. Most of those animals — roughly 900 — are weaned pups.

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It’s “important to keep this in context. So far, avian influenza has affected only a small proportion of the weaned at this time, and there are still thousands of apparently healthy animals in the population,” Beltran said in a press conference.

Public access to the park has been closed and guided elephant seal tours canceled.

Health and wildlife officials urge beachgoers to keep a safe distance from wildlife and keep dogs leashed because the virus is contagious.

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When slowing down can save a life: Training L.A. law enforcement to understand autism

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When slowing down can save a life: Training L.A. law enforcement to understand autism

Kate Movius moved among a roomful of Los Angeles County sheriff’s deputies, passing out a pop trivia quiz and paper prism glasses.

She told them to put on the vision-distorting glasses, and to write with their nondominant hand. As they filled out the tests, Movius moved about the City of Industry classroom pounding abruptly on tables. Then came the cowbell. An aide flashed the overhead lights on and off at random. The goal was to help the deputies understand the feeling of sensory overwhelm, which many autistic people experience when incoming stimulation exceeds their capacity to process.

“So what can you do to assist somebody, or de-escalate somebody, or get information from someone who suffers from a sensory disorder?” Movius asked the rattled crowd afterward. “We can minimize sensory input. … That might be the difference between them being able to stay calm and them taking off.”

Movius, founder of the consultancy Autism Interaction Solutions, is one of a growing number of people around the U.S. working to teach law enforcement agencies to recognize autistic behaviors and ensure that encounters between neurodevelopmentally disabled people and law enforcement end safely.

She and City of Industry Mayor Cory Moss later passed out bags filled with tools donated by the city to aid interactions: a pair of noise-damping headphones to decrease auditory input, a whiteboard, a set of communication cards with words and images to point to, fidget toys to calm and distract.

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“The thing about autistic behavior when it comes to law enforcement is a lot of it may look suspicious, and a lot of it may feel very disrespectful,” said Movius, who is also the parent of an autistic 25-year-old man. Responding officers, she said, “are not coming in thinking, ‘Could this be a developmentally disabled person?’ I would love for them to have that in the back of their minds.”

A sheriff’s deputy reads a pamphlet on autism during the training program.

(Genaro Molina / Los Angeles Times)

Autism spectrum disorder is a developmental condition that manifests differently in nearly every person who has it. Symptoms cluster around difficulties in communication, social interaction and sensory processing.

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An autistic person stopped by police might hold the officer’s gaze intensely or not look at them at all. They may repeat a phrase from a movie, repeat the officer’s question or temporarily lose their ability to speak. They might flee.

All are common involuntary responses for an autistic person in a stressful situation, which a sudden encounter with law enforcement almost invariably is. To someone unfamiliar with the condition, all could be mistaken for intoxication, defiance or guilt.

Autism rates in the U.S. have increased nearly fivefold since the Centers for Disease Control began tracking diagnoses in 2000, a rise experts attribute to broadening diagnostic criteria and better efforts to identify children who have the condition.

The CDC now estimates that 1 in 31 U.S. 8-year-olds is autistic. In California, the rate is closer to 1 in 22 children.

As diverse as the autistic population is, people across the spectrum are more likely to be stopped by law enforcement than neurotypical peers.

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About 15% of all people in the U.S. ages 18 to 24 have been stopped by police at some point in their lives, according to federal data. While the government doesn’t track encounters for disabled people specifically, a separate study found that 20% of autistic people ages 21 to 25 have been stopped, often after a report or officer observation of a person behaving unusually.

Some of these encounters have ended in tragedy.

In 2021, Los Angeles County sheriff’s deputies shot and permanently paralyzed a deaf autistic man after family members called 911 for help getting him to a hospital.

Isaias Cervantes, 25, had become distressed about a shopping trip and started pushing his mother, his family’s attorney said at the time. He resisted as two deputies attempted to handcuff him and one of the deputies shot him, according to a county report.

In 2024, Ryan Gainer’s family called 911 for support when the 15-year-old became agitated. Responding San Bernardino County sheriff‘s deputies shot and killed him outside his Apple Valley home.

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Last year, police in Pocatello, Idaho, shot Victor Perez, 17, through a chain-link fence after the nonspeaking teenager did not heed their shouted commands. He died from his injuries in April.

Autism Interaction Solutions program in the City of Industry.

Sheriff’s deputies take a trivia quiz using their non-writing hands, while wearing vision-distorting glasses, as Kate Movius, standing left, and Industry Mayor Cory Moss, right, ring cowbells. The idea was to help them understand the sensory overwhelm some autistic people experience.

(Genaro Molina / Los Angeles Times)

As early as 2001, the FBI published a bulletin on police officers’ need to adjust their approach when interacting with autistic people.

“Officers should not interpret an autistic individual’s failure to respond to orders or questions as a lack of cooperation or as a reason for increased force,” the bulletin stated. “They also need to recognize that individuals with autism often confess to crimes that they did not commit or may respond to the last choice in a sequence presented in a question.”

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But a review of multiple studies last year by Chapman University researchers found that while up to 60% of officers have been on a call involving an autistic person, only 5% to 40% had received any training on autism.

In response, universities, nonprofits and private consultants across the U.S. have developed curricula for law enforcement on how to recognize autistic behaviors and adapt accordingly.

The primary goal, Movius told deputies at November’s training session, is to slow interactions down to the greatest extent possible. Many autistic people require additional time to process auditory input and verbal responses, particularly in unfamiliar circumstances.

If at all possible, Movius said, wait 20 seconds for a response after asking a question. It may feel unnaturally long, she acknowledged. But every additional question or instruction fired in that time — what’s your name? Did you hear me? Look at me. What’s your name? — just decreases the likelihood that a person struggling to process will be able to respond at all.

Moss’ son, Brayden, then 17, was one of several teenagers and young adults with autism who spoke or wrote statements to be read to the deputies. The diversity of their speech patterns and physical mannerisms showed the breadth of the spectrum. Some were fluently verbal, while others communicated through signs and notes.

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“This population is so diverse. It is so complicated. But if there’s anything that we can show [deputies] in here that will make them stop and think, ‘Hey, what if this is autism?’ … it is saving lives,” Moss said.

Cory Moss and Kate Movius hug

Mayor Cory Moss, left, and Kate Movius hug at the end of the training program last November. Movius started Autism Interaction Solutions after her son was born with profound autism.

(Genaro Molina / Los Angeles Times)

Some disability advocates cautioned that it takes more than isolated training sessions to ensure encounters end safely.

Judy Mark, co-founder and president of the nonprofit Disability Voices United, says she trained thousands of officers on safe autism interactions but stopped after Cervantes’ shooting. She now urges families concerned about an autistic child’s safety to call an ambulance rather than law enforcement.

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“I have significant concern about these training sessions,” Mark said. “People get comfort from it, and the Sheriff’s Department can check the box.”

While not a panacea, supporters argue that a brief course is better than no preparation at all. Some years ago, Movius received a letter from a man whose profoundly autistic son slipped away as the family loaded their car at the beach. He opened the unlocked door of a police vehicle, climbed into the back and began to flail in distress.

Though surprised, the officer seated at the wheel de-escalated the situation and helped the young man find his family, the father wrote to Movius. He had just been to her training.

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