Cultural & Linguistic Competencies & Implicit Bias
Reducing Disparities
The California Medical Association (CMA) believes cultural and linguistic competencies are essential to providing quality and accessible care, and also acknowledges that society has embedded and endemic structural racism and biases that affect the care that an individual receives.[1]
To help bridge the gap, the UCLA Continuing Medical Education (CME) office has created a library of resources on cultural and linguistic competency (CLC) and implicit bias (IB) that reduce health disparities, as well as comply with state law.
[1]References
A substantial body of health-services and medical literature demonstrates that racial/ethnic differences in quality of care persist beyond access alone and are driven in part by system-level (structural) factors and clinician-level bias, consistent with frameworks describing structural racism as embedded across societal systems including health care.
Bailey ZD, Krieger N, Agénor M, et al. “Structural racism and health inequities in the USA: evidence and interventions.” The Lancet. 2017;389:1453–1463.
Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463. Doi:10.1016/S0140-6736(17)30569-X
Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. National Academies Press. Published 2003. Accessed January 2026.
Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003. Doi:10.17226/10260
Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-125. Doi:10.1146/annurev-publhealth-040218-043750
Yearby R. Structural racism and health disparities: reconfiguring the social determinants of health framework to include the root cause. J Law Med Ethics. 2020;48(3):518-526.
California Medical Association’s (CMA) Definitions
Cultural and Linguistic Competency (CLC)
The ability and readiness of health care providers and organizations to humbly and respectfully demonstrate, effectively communicate, and tailor delivery of care to patients with diverse values, beliefs, identities and behaviors, in order to meet social, cultural and linguistic needs as they relate to patient health.
Implicit Bias (IB)
The attitudes, stereotypes and feelings, either positive or negative, that affect our understanding, actions and decisions without conscious knowledge or control. Implicit bias is a universal phenomenon. When negative, implicit bias often contributes to unequal treatment and disparities in diagnosis, treatment decisions, levels of care and health care outcomes of people based on race, ethnicity, gender identity, sexual orientation, age, disability and other characteristics.
Diversity
Having many different forms, types or ideas; showing variety. Demographic diversity can mean a group composed of people of different genders, races/ethnicities, cultures, religions, physical abilities, sexual orientations or preferences, ages, etc.
Exemptions
As defined by the bills, the exemption provisions are for CME activities that are research-based or contain no direct patient care component. Exemptions must be validated with documentation demonstrating the absence of relevance of CLC/IB material.
Resources
- Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
- Adverse Childhood Experiences: Tips to help you support inclusivity and equity
- Enhance Patient Care Through Better Cultural Awareness
- Implicit Stereotyping and Medical Decisions Article
- Culturally Competent Healthcare Research Article
- Culture and the patient-physician relationship: Achieving cultural competency in healthcare
- Health Disparities by Race and Ethnicity: The California Landscape
- Systemic racism and U.S. health care
- Quality of evidence revealing subtle gender biases in science is in the eye of the beholder
- JAMA: Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018
- JAMA: Assessment of Mortality Disparities by Wealth Relative to Other Measures of Socioeconomic Status Among US Adults
- Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
- Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research
- Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients
- Culture and the patient-physician relationship: Achieving cultural competency in healthcare
- AAMC Cultural Competence Education
- NIH: Patient Centeredness, Cultural Competence and Healthcare Quality
- Viewpoint: Physician, Know Thyself: The Professional Culture of Medicine as a Framework for Teaching Cultural Competence
- Unconscious Bias Training That Works
- Health Disparities by Race and Ethnicity: The California Landscape
- Systemic racism and U.S. health care
- JAMA: Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018
- JAMA: Assessment of Mortality Disparities by Wealth Relative to Other Measures of Socioeconomic Status Among US Adults
- Industry Collaboration Effort: Introduction for Healthcare Professionals
- Industry Collaboration Effort: Better Communication, Better Care: Provider Tools to Care for Diverse Populations
- Industry Collaboration Effort: Cultural Competency and Patient Engagement
- Culture and the patient-physician relationship: Achieving cultural competency in healthcare
- Health Disparities by Race and Ethnicity: The California Landscape
- Systemic racism and U.S. health care
- JAMA: Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018
- JAMA: Assessment of Mortality Disparities by Wealth Relative to Other Measures of Socioeconomic Status Among US Adults
CMA’s Continuing Medical Education CLC & IB Standards FAQ
Why were these standards implemented? Why now?
California Business and Professions Code (B&P) 2190.1 mandates that continuing medical education (CME) courses include curriculum that includes understanding of cultural and linguistic competency (CLC) and implicit bias (IB) in the delivery of health care, and further mandates that evaluative standards be developed by January 1, 2022.
The standards were developed to help reduce health care disparities by ensuring that CME activities in California reflect this important aspect of caring for patients.
The requirement to address CLC in California-based CME activities has been in place since 2006. The new IB requirement now provides an opportunity to provide a framework for supporting the adoption of these requirements universally.
What legislation does B&P 2190.1 come from?
The CLC and IB standards are codified into B&P 2190.1 from Assembly Bill (AB) 1195 (Coto, 2005) and AB 241 (Kamlager-Dove, 2019).
Why is the California Medical Association (CMA) creating the standards?
CMA has been delegated the authority to create these standards for California CME providers by the Medical Board of California. As the accrediting body for CME by and for California’s physician educators, CMA is in the best position to develop standards that reflect the needs of the community it serves.
How were these standards developed?
CMA worked with an advisory council with expertise in CME and health equity beginning in October 2020 to develop standards that would be meaningful and relevant to all types and sizes of CME providers; the Accreditation Council for Continuing Medical Education (ACCME) also provided input and support. Draft standards were presented for public call for comment in April-May of 2021. Comments were reviewed by CMA, and the advisory council made relevant adjustments prior to the final release.
When do these standards go into effect?
The CLC and IB standards are effective January 1, 2022.
Who is required to comply with these standards?
All CME providers located in California.
I am a California provider accredited by the Accreditation Council for Continuing Medical Education. Do these standards apply to me?
Yes. The statute is written to apply to organizations accredited by both CMA and ACCME in California.
I am an out-of-state provider accredited by CMA. Do these standards apply to me?
No. CME providers located outside of California are not required to adhere. However, organizations are encouraged to utilize the resources to help address these important topics.
What if the CME activity takes place outside of California?
CME activities that are planned and implemented by a CME provider located in California must adhere to the standards, regardless of where the activity is held.
What if the CME activity learners are outside of California?
The standards apply to CME activities planned and implemented by CME providers located in California rather than the learner's location. All accredited activities by CME providers located in California must include the CLC and IB standards, regardless of where an activity is held.
Are there exemptions?
Yes, a CME course dedicated solely to research or other issues that does not include a direct patient care component is exempted.
How will this affect my accreditation?
CMA and ACCME expect that you will comply with state regulations as part of your adherence to the ACCME CME Program and Business Management Procedures Policy.
At initial accreditation and reaccreditation, as well as during the annual reporting process, you will be asked to attest that you have complied with all ACCME requirements, including this policy. Adherence with the law is separate from your accreditation decision.
What if these standards are not relevant to the topic of the CME activity?
The standards have been developed to be broad and fit the needs of all types of providers and topics, and most topics should be able to include relevant education on CLC and IB. Providers are encouraged to explore the resources, as well as make use of the many CLC and IB tools created by credible medical, academic and research organizations.
If providers are unable to identify relevant materials, they should evaluate whether their content falls into the exempted categories (research focused and/or contains no direct patient care component) and make appropriate documentation in their files.
Where do I find resources to help me?
CMA will provide ongoing support and resources at cmadocs.org/cme-standards.
Do the standards apply to all CME activities?
Per B&P 2190.1, all accredited CME activities with a direct patient care component are expected to include CLC and IB unless the activity is research focused.
How does this work for a regularly scheduled series (RSS)?
An RSS is considered a single activity, and CLC and IB should be included as appropriate (in at least one session for example), unless the RSS is focused on research.
How can I modify my existing content to comply with the standards?
View the “implementation resources” on CMA’s website for ideas to incorporate CLC and IB into CME.
Do these standards align with commendation criteria?
The standards and best practices were designed to align with some of the components of the commendation criteria. Just as in the commendation criteria, the CLC and IB standards are designed to be flexible to fit the needs of all types and sizes of CME providers in ways that are meaningful and achievable. CME providers are encouraged to consider ways to incorporate commendable practices that meet CLC and IB standards and criteria.
What is the difference between the standards and the best practices?
The standards incorporate CLC and IB into CME activities throughout the planning process, as well as give planners and speakers the tools needed to include them in a manner that works best with the content.
The best practices can be utilized with the CME activity and at the program and organizational level.
Why were the best practices developed?
While not required for compliance with the law, the best practices exemplify how CME programs can excel in this work.
Source: California Medical Association