California is notorious for intrusive laws, but when it comes to the medical field, regulatory growth is particularly sprawling.
asserted
growth → come → field
As a condition of license renewal, California physicians must log 50 hours of approved continuing medical education (CME) courses every two years.
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physicians → log → courses
In 2022, the Golden State started requiring physicians involved in direct patient care to take CME courses that include training on implicit bias, which the state defines as the "attitudes or internalized stereotypes that affect our perceptions, actions, and decisions," contributing to "unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics.
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that → start → race
This requirement violates free speech, according to a group of California doctors who are asking the Supreme Court to hear their case and declare the law unconstitutional.
uncertain
law → violate → case
The justices are scheduled to consider the petition at their September 28 conference.
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justices → schedule → conference
One of the plaintiffs, Azadeh Khatibi, is an Iranian-born physician who moved to the U.S. when she was 6.
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she → bear → U.S.
After completing her joint medical degree program at the University of California (U.C.), San Francisco, and U.C., Berkeley, she became an ophthalmology specialist in Los Angeles.
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she → complete → Angeles
She has taught CME courses in California for several years.
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She → teach → years
"I think it is dangerous for the state to mandate the speech of physicians when they are teaching other physicians, and for the state to get overly involved in the practice of medicine," Khatibi tells Reason.
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Khatibi → think → Reason
"I've never said I dislike implicit bias training.
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I → say → ?
I've actually taught mindfulness and about the power of the subconscious mind," but "the data on implicit bias training is still nascent and controversial."
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data → teach → training
"This law, which requires the teaching of strategies as a major part of it, is not based in science," she adds.
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she → require → science
"Not only is the state mandating the private speech of doctors, which is unconstitutional, it is furthermore mandating speech on a topic around which the science and methodology are poorly evidenced."
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science → mandate → which
Indeed, there is little evidence that compulsory implicit bias trainings actually reduce discrimination.
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trainings → be → discrimination
A 2019 meta-analysis covering 492 studies and more than 87,000 participants found that interventions "generally produced trivial changes in behavior," and there is "little evidence that changes in implicit measures translated into changes in explicit measures and behavior."
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changes → cover → measures
In some cases, these trainings have been found to increase discrimination.
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trainings → find → discrimination
A 2026 study published in the Journal of Personality and Social Psychology found that mandatory "diversity training leads to increased reactance."
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training → publish → reactance
To Marilyn Singleton, one of the plaintiffs in the case, these diversity requirements can also hurt patients.
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requirements → hurt → patients
In a 2023 Washington Post op-ed, in which she described her experience as "a Black woman in a [medical] class of mostly White men," Singleton wrote: "Black people are, in effect, being told that White physicians are likely to quite literally damage our health.
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physicians → describe → health
If that's the case, why on earth would you seek medical care, unless you could be absolutely certain of not being treated by a White physician?
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you → seek → physician
"Requiring every instructor of continuing medical education to include discussion of implicit bias is compelled speech that the First Amendment prohibits," Caleb Trotter, a senior attorney at Pacific Legal Foundation who is representing Khatibi and Singleton, tells Reason.
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who → require → Reason
"This is compelling instructors to teach this specific subject matter, whether they like it, whether they agree or believe in it or not, and whether they even have any expertise on it.
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they → compel → it
In August 2023, the doctors, along with the medical advocacy organization Do No Harm, filed a federal lawsuit in the District Court of the Central District of California, which the court later dismissed.
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court → file → which
In 2025, the 9th Circuit Court of Appeals rejected the plaintiffs' challenge and affirmed the district court's ruling.
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Court → reject → ruling
The appellate court held that California's implicit bias requirements in CME training amounted to "government speech"—a legal doctrine that says the government can speak for itself without being barred by the Free Speech Clause—and therefore did not violate the First Amendment.
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government → hold → Amendment
"So what they're saying is: Continuing education is government speech just as the same as if it was a state employee, a state public school teacher, or the 'Got Milk?' advertising campaign from years ago," says Trotter.
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Trotter → say → Milk
He argues that California is trying to stretch that principle to cover "private speakers speaking in their private capacity in private courses accredited by private organizations."
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California → argue → organizations
Trotter describes this law as a "massive expansion of the government speech doctrine," saying that if the Supreme Court does not prevent it, "there's nothing to stop any state in the future from requiring professionals of all kinds to include any manner of the hot social topics of the day in professional licensing."
The Supreme Court has ruled in favor of free speech in similar cases.
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Court → describe → cases
In NIFLA v. Becerra (2018), the Court ruled that California could not force licensed pregnancy centers to advertise state abortion services simply because they were regulated professionals.
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they → rule → services
The ruling stated that "this Court has never recognized 'professional speech' as a separate category of speech subject to different rules.
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Court → state → rules
Speech is not unprotected merely because it is uttered by professionals."
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it → utter → professionals
California is not the only state that now mandates implicit bias training for medical professionals.
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that → mandate → professionals
In 2020, Michigan Democratic Gov. Gretchen Whitmer issued an executive directive establishing the same requirement, which the Pacific Legal Foundation is challenging in court.
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Foundation → issue → court
Massachusetts, Washington, and Maryland all have similar requirements, with Maryland requiring both implicit bias and "structural racism" training for all first license or certificate renewals.
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Maryland → have → renewals
These laws are examples of a myriad of occupational licensing restrictions that gatekeep work and push up prices.
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that → push → prices
Because the United States has "a very large, intrusive occupational licensing regime," says Trotter, we end up with "inevitable mission creep."
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we → have → creep
Roughly 1 in 5 employed Americans now need a government-issued license to do their jobs, and those barriers raise prices by restricting competition without necessarily improving public safety.
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barriers → employ → safety
This case does not just have implications for free speech.
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case → have → speech
It is also a warning about what happens when governments gain expansive power to decide who is allowed to work—and on what terms.
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who → happen → terms
The Aporia
