 This is the House Healthcare Committee. It's Friday, February 26th, just after 11 a.m., returning from our floor session. So this morning we're taking further testimony on H210, which is the bill on health equity. And we have with us witnesses from the Vermont Medical Society. And I'm going to leave it to welcome you to introduce yourselves for the record and also to determine who wishes to speak first. Great, for the record, I'm Jill Sutthoff-Garron and I will be speaking on behalf of the Vermont Medical Society, the American Academy of Pediatrics, Vermont Chapter, the Vermont Academy of Family Physicians and the Vermont Psychiatric Association this morning. And we will all be expressing our support for H210. And I will also introduce Jessa Barnard, our Executive Director of the Vermont Medical Society. We thought it would make sense if I talked about just the background of our work and addressing inherent bias in healthcare. And then Jessa will talk specifically about achieving meaningful medical training in this area. So I wanna just start by framing the message that our organizations have made recognizing, addressing and mitigating the impact that inherent bias has on health outcomes, one of our very highest priorities. And I will also say that we are very much in the listening stage of this work in order for us to really thoughtfully create health equity tools that we can appropriately apply to better serve our patients. We really need to listen and we really need to take input from the communities that have been historically silenced and marginalized. And we've really seen the poorer health outcomes in these communities as well. Last week, VMS hosted a webinar and it was called Just Race and Health Equity and it was really looking at what the American Academy of Pediatrics Task Force on Race and Health Equity. This is a task force that was formed last year when the George Floyd murder happened. And so the webinar was really looking at their work and what they're trying to do. This is a 25 member task force mostly made up of pediatricians. And Becca Bell, the pediatrician intensivist who's leading the webinar, she said, we're really in the beginning of the discussion of how we approach this work. We very much in the process stage and we need to take our time. So at the very minimum, we do no harm. And really in order to do that, you really need to take that time to be informed by the communities and really not try to put a one size fits all approach in terms of tool kits or practices or anything of that sort. So we really resonate with that message. Last June, VMS like the rest of the world was really gripped by the murder of George Floyd and we took that time to put out our statement, not only denouncing police brutality, but also really naming systemic racism as a public health threat. We know that systemic racism and other forms of discrimination have really produced devastating health impacts. And these impacts, we've seen it with trauma, chronic stress and the differential access to appropriate medical care. And then of course with COVID, that's really exposed what happens with this differential access to care and it's led to tragic disparities in health outcomes. So really the need for culturally appropriate public health measures, including those with social determinants of health and mitigating this disproportionate impact is really important and critical right now. Since I began working at the VMS, this has been like one of our very, very highest priorities. And in 2018, we actually adopted a policy in which we resolved support system designed to combat biases within the healthcare system, not just for the patient, but also for patients that we're choosing not to go to specific healthcare providers because of these biases as well. In 2018, we also adopted policies to support the humane treatment of migrant families just because we saw so much heartbreak on the border and our members really took an active role in addressing this. And then VMS also adopted a policy in 2019 to protect women's reproductive rights just really with the idea that the sovereignty of your own body is integral to your health. So I will just say that over the last years that I've been at VMS, I've just seen that our members are super hungry for this education, they wanna learn more, they wanna take an active role. And so we are very supportive of this bill and we are very supportive of the office, the idea of the Office of Health Equity. We sent a memo earlier, I don't know if Colleen put it up, but in the memo, I have a number of webinars and trainings that we've put out and partnered with other organizations on. I don't know if it would be helpful for me to pull that up for you to look at, but. Yeah, I think we have the memo, so I think that would be sufficient. In terms of the best use of our time this morning. Yeah, but you'll see that VMS has a webpage on this where we're consistently putting up new information. Our annual meeting is always included health equity trainings. And then there's really good resources being put out with partner organizations, Vermont Program for Quality Healthcare is gonna be doing something with Dr. Avila, which you just had her in this week. And then the areas of health education centers has a great five-part series that's really looking at cultural competency. So just to emphasize that this work is being done and that we are highly supportive of it. I guess we have a couple of suggestions for you and then I'll turn it over to Jessa, but yesterday's Zuzana Davis talked about maybe just starting with the advisory commission and we would support that. We feel like right now the Vermont healthcare system has just been underwater and then BDH, we know that their capacity is so low right now. So we would say that that is a great first step. We also noticed that beyond the commissioners of health and mental health, there are really no healthcare providers on this commission and we would urge you to have clinicians on this commission just understanding that you're trying to develop new systems of care. And so you really wanna have people that can inform with their practice experience, but also just to have the accountability and the buy-in on the ground. So we would support that. We also support section 252 and in Kay, you talk about working collaboratively with UVMC, which we know has done a lot of work in this area. We would also urge you to partner with AHEC and VPQHC just because they're doing the work in this area. And with that, I will turn it over to Jessa and then we'll be here to answer any questions afterwards. Thank you. Thanks so much for having us. Thank you, Jill, for that great framing of the work we've been doing in the area and the interest of our members. And so continuing in the theme of suggestions in the section on mandatory education, we would really encourage the committee to look at the approach taken to professional education in S42-48 that Dr. Avila mentioned in her testimony. This was in one of her slides. This is a bill that's been introduced in Congress. I don't believe it's been passed, but we really appreciate the approach taken by that bill. It directs, in this case, on the federal level, the Secretary of Health and Human Services to award grants to a range of entities, healthcare providers, health departments, professional schools, nonprofits, to support bias and anti-racism training to reduce racial and ethnic disparities. And then it links any entity that's receiving that grant funding to reduce those trainings needs to meet some criteria. So the education has to be evidence-based, community-informed, patient-centered and ongoing. It needs to be culturally competent and accessible. And I think this is really key. It needs to be designed to allow any state licensing body to provide continuing educational credit for those courses. So it needs to be recognized by whatever your licensing board is as meeting whatever hour requirements you have for CME already in your licensing standards. We really support that approach. We think there should be funding and support for the development of courses and the ongoing implementation of those courses and that it should fulfill existing CME requirements. That said, I will move into the reasons we, actually we don't support the current language in the bill regarding a list, a specific list of topics that need to be repeated every two years in order to, as a new licensing requirement. So a lot of these concerns stem from our experience having, seeing our members going through the required courses for the opioid training. So what we've seen is that just having a mandatory hour requirement does not necessarily mean quality education or desired behavior change necessarily. So for example, with the opiate training the quality of education varies widely. We've seen out of state for-profit companies, market CMEs because they know that providers are required to take it. But it's, but in our opinion it's not been very high quality training. And on the other hand, we have some Vermont based entities that offer excellent training in this area. But again, it varies widely. I am not an expert in the science of continuing medical education. There are people out there who are like at AHEC or VPQHC, but I am aware that the research shows the efficacy of CME can vary widely based on how it's done. Its methods, its length, how important it is to the person taking the education. And we got a really, I thought helpful quote from Nicole appointed to the end of our memo who's the executive director of the Northern Vermont, AHEC. And again, it's not specific. She doesn't have a position on this bill, but she did weigh in that she's not aware of a strong evidence base that supports state mandated low contact educational activities to support change in a highly complex area such as this one. So again, with the listed topics that need to be repeated, we think that that could be a useful baseline level of education, but real change is I think we all acknowledge goes far beyond a course, especially in this area of healthcare. We need changes in medical school and residency curriculum, which we are seeing happen, but that needs to continue. Changes in organization and practice level policies, procedures, screening tools. As Jill mentioned, absolutely critical to have conversations with impacted patients and families and changes in workflow and more. And Jill referenced this task force, this Vermont task force of pediatricians really delving into this work. And we see other specialties interested in this work. And in contrast, we worry that requiring the same topics on the same education to be offered year after year does not necessarily continue to move the needle in terms of behavior and culture change. And again, to this point of the opioid training, similarly, as section four, B2 of this bill does, that lists topics that need to be covered. For example, storage and disposal of medications, safe use of medication using VPMS, state laws. And that means that it needs to be a very prescriptive course. There aren't very many courses, honestly, that meet that requirement. And it actually means it doesn't always meet the needs and the interests of certain specialties and clinicians. So we've had members ask for trainings on innovative new research, regarding using CBD or cannabidiol to manage pain or opioid replacement therapy and how that can be adapted to the COVID-19 pandemic, pain management and surgery. All of those are topics that I think we would all agree are important and probably really relevant to certain specialists, but because there's sort of a list of topics that needs to be covered, the Board of Medical Practices had to say, we're sorry, that might be really interesting to you, but doesn't meet this topic requirement. So we would really like to see more flexibility to ensure that education is engaging and relevant to different specialties and practice types. Also, I wanna make a point, I listened really closely to Dr. Avila's presentation. I've actually heard her presentation to the VAH, the hospital association as well. I think she's an excellent speaker, raised a lot of really good points. And she mentioned the language access piece a lot. And I wanted, in my mind, I wanna distinguish that a little bit from cultural competency. I know they're intricately related, but I agree with her, that's a black and white compliance issue. We've been providing information to our members for years that you need to provide translation and interpretation services. It's in our guide to law, on our website. Practices should be doing that, just like all other compliance issues like disability accommodations, complying with employment law requirements. To me, that's again, a black and white compliance issue. We would be happy to continue to remind our members of that. I think it'd be great for the licensure boards to remind their members of that legal obligation. I think that's a little different, again, than a broader educational topic to me on cultural competence, that she, as she mentioned, goes to a lot of sort of emotional level issues and relating to patient issues. So I do wanna just acknowledge that issue and say we completely agree that that's important information, but to me a little more black and white to disseminate to our members. So just in conclusion, I wanna say as with many in society, our members have become much more actively aware of this issue and engaged in this issue of existing and longstanding disparities in society and within the healthcare system and the shortcomings of our healthcare system in the past. And we take responsibility for the special trust put in healthcare providers to meet the needs of our patients. And we support educational efforts, but many of these are really just getting off the ground. Jill mentioned the new training created by AHEK, the five part series, that this series by BPQ is actually just happening this spring, they've just pulled it together. So we support sustaining those, disseminating those, and while we think we're nowhere near the end of this journey, we also don't think now is the time that we necessarily need a list of prescriptive topics to be offered or required every two years. So with that, happy to answer further questions. Oh, and I'm sorry, we've been using some acronyms. Jill and I even yesterday said no acronyms and here we are. So BPQ is the Vermont Program for Quality and Healthcare. They are a state, sorry, they're a nonprofit that's really focused on quality improvement and education around the state. And then I think there was a question, AHEK Area Health Education Centers, there's a central office out of UVM, but then also regional offices around the state and their whole mission really is developing the workforce pipeline and workforce education for healthcare providers. I know you have such limited time for testimony on this bill. I would love if you could hear from them and hear about all their work to design these courses. They again are really the experts and leaders in health education that may not be possible given your time, but maybe they could at least submit some written more information about the courses they're doing and how they've developed them. I think that might be valuable for you to hear again. We just, we're really here to emphasize that how seriously healthcare providers take this issue, how committed they are and that this work is really, as I said, just I think growing every day. Thank you both. Thank you very much. And let's hear some questions. I know I have some questions and when I see some hands from community members, let's go first to represent Cheetah and then represent Paige. Thanks for your testimony today on the issue and for giving us an update on some of what's actually happening in the area of training especially. And when this bill was being written, it was finished quickly. So one of the pieces about the training is that it was more of a placeholder than anything with an understanding that two hours of training is only gonna do so much on any topic. And when you look at cultural competency and anti-racism training, it's culture change and it's ongoing work that really makes a difference. And so I'm wondering, it sounds like you have concerns about moving the bill forward with that piece on it for those reasons, might it make more sense to ask the commission to do some ongoing work in this area with healthcare providers and come back to the state with a report on requirements over time? Because as I'm hearing you, I'm thinking that might make more sense and I'm looking at the bill now and I don't think they have that specific duty, but I don't know what your thoughts about maybe that would be a way to address your concerns without losing sight of why it was in there to begin with. I love that idea. I would love to hear from the commission about their recommendations, what other states are doing. Personally, I would suggest involving the licensing boards in that. They may have suggestions about how to promote this, how to engage with their licensees. So yes, absolutely. I think healthcare providers would be very interested in their recommendations and working on this issue. I think it's a great suggestion. Yeah, so maybe it sounds like what I'm hearing. I don't know if anyone's writing this down. So maybe I should, but like what I'm hearing is something like the commission would work with the appropriate licensing boards of the health professions to come forward with any recommendations for requirements or something like that. Yes, off the top of my head, that sounds like it. Yes, ideally working with the healthcare boards and healthcare providers, I think would be even more inclusive, but yes, I think that idea would be very welcome. Okay, I'll write it down. And I think you've heard you say this to the committee previously, but we would encourage it to be as you, I think you've said for all healthcare professionals, I know you said as well that it was sort of a placeholder just to put one group in there, but we would support that. All right, thanks. I'll take a note for us for later. Please, thank you, Representative China, because I don't think we have Lynch Council available to us this morning, but we will be working with them to craft revisions to the bill as presented to us. Representative Page and then Representative Peterson. Yes, thank you. I was curious, well, actually I have a couple of questions. One, would you say that cultural competency is being presented in our medical schools today? Do you have any knowledge on that? I believe it is, and I should, you really should hear from the medical school directly about that, so I'm probably not the best witness on this. My understanding it is now a required part of most medical professional training programs, not just medical school. And to maintain one's practice, how many, what type of refresher training or courses are required to continue to be licensed? That's a, so great, thank you for that question, because I actually want to point out that state statute, so it varies based on profession. So I will speak for MDs, licensed by the Board of Medical Practice only, because that's where our members sit. I believe state statute, and I saw this edit in the bill or the change in the only requires 10 hours per two-year licensing cycle. I will say by rule, the Vermont Board of Medical Practice goes beyond that and requires 30 hours total every two years, because that's the two-year licensing cycle. There are, by state statute, there have been a couple of topic-specific areas that are required that go towards that 30 hours. Currently, one is on hospice pain, we might get this a little bit wrong, palliative care, hospice and pain management, and then two hours if you have a DEA license and prescribed controlled substances needs to be on prescribing of controlled substances. So three hours out of your 30 hour requirement are currently prescribed. That's been added by state statute, by the legislature, not by the Board rules. On top of that, many, almost all physicians, many, many physicians have board certifications, so you could be board certified as a pediatrician or a family physician in your specialty area. That typically requires many hours beyond that 30 hour every two years. I believe, again, might not be quite right on this, I believe for family physicians, it's something like 100 hours every two years. So again, the current 10 hour in statute is a very bare minimum that goes well beyond that. Okay, thank you. And then we all recognize how important healthcare is for all Vermonters. But do you have any examples, specific examples of health disparities in our healthcare providers or within the month's practice of medicine? Where it would show that perhaps we have a problem or maybe we don't have a problem? Looks like Jill wanted me. I will say that we have recent data that shows the percentage of our BIPOC population that's been disproportionately impacted by COVID. That's just immediate data. And we know that there was kind of a slow data catch on this in general, we've heard that. So we know that our BIPOC population makes up about 6% of Vermonters, but they were 18% of them were impacted by COVID. So that's a much higher impact. That's just a very small example. Yesterday you heard a lot about the LGBTQ community where there's many impacts. There's also just the impact of just the population health and the social determinants of health that increase poor health outcomes. You heard just as a small example, the LGBTQ youth use tobacco at a much higher rate than the rest of the population in Vermont. And that's because they've been mercilessly targeted by the tobacco industry. There's a number of things that we could show but just immediately really looking at the COVID, that's a prime example. But you don't have any reports or specific cases against individuals that are available to the public? I'm sorry, specific cases, you mean log cases or? Yeah, I guess where there's been a, you know where the patient has complained about, you know, certain providers not taking their... Yeah, I think we may not have that data as, you know, we're not the public health department, we're not the licensing entities we have heard. So we don't have a report to show you. I can say anecdotally and, you know, a lot of the testimony you've heard, we know. And I think actually Dr. Avila did an excellent job of saying we all have biases. You know, we all come into this world with judgments we're making about other people. And so we know just like the example she gave of the car dealership, we know healthcare providers come to their job with the same biases other people have. And, you know, acknowledging again that healthcare providers have a special trust with their patients. So healthcare providers are not just a person off the street, they are responsible for creating a trusted relationship with this person and listening to them and acknowledging that we may be missing things. You know, there's a lot of emerging data, things like how are we even using, is race even a legitimate reason to be making diagnoses? In some instances, maybe it is actually a factor, but in many instances, you know, we know race is not a biological fact. You know, we've learned, many of us grew up kind of thinking that, but we actually, in reality, you know, our genetics do not line up with what we may look like racially. And so there's a lot, you know, I think it's a huge topic from all the way from inherent bias to the actual, you know, some of the data in diagnosis and treatment. And so that's why I think we, again, we were coming at this from, there's a lot of healthcare providers can learn about this in a whole different, in many different ways. And so we want to promote that whole range of education. So I mean, I guess to your point, I don't, we are not coming to you today with a specific example, but we know hearing from patients that they have been treated differently and it has impacted their trust in the healthcare system. Okay. And I guess those are particular, maybe particular feelings with the individual, but well, just that's that. Okay. Thank you. Okay. Representative Peterson and Representative Goldman and Representative Cortis. Yes. Thank you. Thank you both for your testimony. The training that you envision, does it involve medical training at all or is it training around how to treat people maybe? What do we see for training that would stop health disparities? I don't know even how to frame the question other than are we getting into the medical part of things or is it something else? I think all of the above is what I was, maybe I didn't do as clear a job as I intended answering this to the last question. I think there are a lot of aspects of this issue from the basic science. What are we learning about diagnosing whatever? I'm not a clinician, so I'm kind of making this up here about a pathologist. Maybe there are things they need to know about differential diagnosis that has a basis in somebody's racial differences, but again, maybe not. Maybe it's let's unlearn things. Maybe we learned 20 years ago in medical school, what's the up-to-date knowledge about this? Some of it could be very clinical. I think there is an aspect absolutely that's around behavior change, listening to patients, the inherent bias we all bring to our life and our profession. And then there's also a lot around practice change, not the clinical practice, but just how we approach our patients and from how the receptionist greets somebody to the checklists and tasks. Does a patient feel welcome at the office? How do we set up our waiting room so that everybody feels included? I mean, it's a very, and again, I don't want to claim I'm an expert in this area. That's why, and again, Becca Bell, the pediatrician, one of the pediatricians leading this effort has said, it's about listening. We need to hear from the patients what we're doing wrong and what we could be doing better. So I think there are many aspects of this issue and ideally education could eventually and is addressing all of those facets. Yeah, and I will just go back to the task force. One of the things in the webinar that Becca Bell talked about that they're working on is creating a culturally safe medical home. What does that mean? What does that mean for our children? What does that mean for our families? So when you talk about medical training, it's really how do we even just start that trust because going back to what Jess has said, this is, people have to trust their physician if they're going to be open about their healthcare issues. And so really creating that safe space is probably like the first step, one of the first steps. So yes, there is behavioral and scientific change that needs to happen. Thank you. Representative Goldman, Representative Cordes and then Representative Lipper. I just wanna take a breath for a minute and take us all back to experiences we've had in exam rooms with medical professionals. There is an important power dynamic inherent in that relationship that cannot be overstated. There is implicit biases that come into it. When we all go into exam rooms, it can be a pretty frightening experience. They're stepping into the room. You don't know what you're gonna hear. You're frightened. There may be something wrong with you. There may not. And if you're in this exam room with a person who is biased against you, it really affects your experience to be honest, to be open and to trust the outcomes. So I think that raising consciousness of providers to understand that power that they have, that's implicit in their position is crucially important. I think because those of us that do this work sort of live in that soup, we often don't recognize it as much as we need to. And I think that that is really important and an opportunity to do better care for people that we care about and that we wanna be healthy. So yes, I think that there's a huge opportunity for learning. There isn't always data because it's subtle. It's implicit. It's based in power. And there's this knowledge dynamic, but there's also the power dynamic. So yes, let's do more work on this. Thanks. Thank you. Representative Cordes. I wanna take a moment to focus on what I am hearing, seeing and sensing is a resistance to believing the testimony that we've heard thus far from providers, from doctorate level professors, from representatives of communities that total tens of thousands of people in Vermont, representing tens of thousands of people in Vermont. From providers like myself, I'll reiterate, I've been a nurse in Vermont for 32 years. I've already said that I have witnessed, my colleagues have witnessed, we talk about it, this kind of bias and systemic bias exists. It's endemic, it's really hard to move. And it's frustrating actually to feel like we're spinning the wheels here and by dismissing the incredible testimony that we've heard this far. And as I just have to point out that the people that we've heard testimony from are largely identified as women and people of color. And I don't know if that plays into any of the resistance any of us are feeling, but it's really super hard to watch that play out in this committee. Thank you for your comments, Representative Cordes. And I'm going to, while I share some of your concerns, I'm going to suggest that we all reserve our concerns for committee discussion rather than for witness testimony where possible because I think some of the same questions have, I think we need to, I share the concern. I feel like at this point, if we have had many witnesses establish the presence of health disparities in the state of Vermont, and I don't know if there are members who really don't believe that that's the case, we can have a further discussion about that. But I think at this point to question witnesses asking for further evidence of that in order to discuss some of the other matters before us is perhaps, well, it's challenging. But I think we can have that discussion when we have our committee discussion. We do not all have to share the same point of view, despite the witnesses that we've heard. So I would like to raise a question because I remember in some of the testimony we heard from Dr. Avila, in fact, one of the comments that resonated for me was that if we don't have requirements, things don't happen. I mean, we can have all the best intentions in the world and I'm going to be candid and say, like you can give us all the assurances that we're really working on this and we're really going to do it. But in fact, some of us also understand that, in fact, I think you shared here this morning some evidence of the fact that language access, it clearly isn't fully happening despite there being federal law, probably requirements from licensing boards as well as quote reminders from professional organizations. So it is a concern to me to just, I mean, I think Representative Chiena had a very helpful suggestion as a way we might move forward. But I also, frankly, am personally concerned that if we don't have some requirement to undergird what might come from the commission or others, that we have no assurance that things will really happen. Now, so my question in part is, I believe Dr. Avila referenced, and if I'm remembering this wrong, others can correct me, but I believe she referenced the fact that there are numbers of states that have professional training requirements for healthcare providers around cultural competency that are actually requirements, not voluntary professional organizations goals. And so maybe I'm making more of a statement, but I'm curious as to what your understanding is of other states' requirements around cultural competency in terms of professional healthcare provider requirements. Yeah, thank you for that question. I have not done a systemic analysis. I believe she mentioned, if I have this in my mind, there were maybe 22 states where it had been introduced. I'm in the 20s, yes. But I think that's been, yes. I think it's, I believe it's only passed in California. There may be one, maybe Washington DC, I'm not positive about that. So there's been legislation introduced. I don't believe it's in place in very many states currently. And I think it's a good question. I guess my response is I think this, if she had been saying this 10 years ago, I would say I agree that there is sort of a lack of baseline interest and desire, not desire may be the wrong word, a lack of awareness. I do think there's been such a growth in the awareness and our own awareness of our lack of information in this area, just seeing it from our own members, I think representative Tina's idea is great. One of the things maybe that group could look at is how broadly it's already been, what the uptake has been with it being voluntary. I don't have that data for you today. So for example, how many providers have already gone through the trainings or are we going through the AHEC and PPQ trainings or does it look like we have a big gap? I'm sure at this point it's not yet everybody, but I will say again, I think there has been a lot of uptake and that my main concern is also that it about it being the same requirements every two years where I think we want to get, again, that may establish a baseline, but I think we need to, I think a more systemic look at what we could be doing to then continue to move the needle would be helpful. And asking that of the licensing boards and the professions to say, how can we make this an ongoing issue you're paying attention to? To the language access piece, I do want to address that because I'm sure I don't want to dispute that there are some practices that are not complying with this. The questions I get from practices are how do I comply? Not whether not do I need to do this, but how do I do it? What services should I use? We actually, VMS is a member benefit, has a discount contract with a language translation service for our members. So, again, not that I've surveyed our members, but I have not experienced, of course, I maybe I wouldn't hear from the ones who don't know they have to do it, but that it's more of an issue of how do we do this? Do you have suggestions? Do we get reimbursed to representative Black's point? I think that is, unfortunately inserts tension in the relationship when practices want to be doing this, but if they're not getting paid for it, it can become quite expensive. And so that's just it's an additional factor we've had. That's typically the question I'll say we get from practices is I know I need to do this, but do I need to pay for it? And I think honestly, that's one of the issues why sometimes practices would want to be able to rely on family members when that's not best practice, because then it's obviously less expensive. So I think there are tensions there, but I don't know it's as much a lack of knowledge that they need to be doing it. Yes, it's always a challenge when we hear testimony that when asked for a specific instance, Dr. Navila shared her experience with her mother and that was not just once or twice, but 47 times. Yeah, I can't dispute that. I mean, that's surprising to me, that's disappointing to me, I agree with you. Yeah, so can I just ask you want to just, I want to make sure I understand because you several times referenced prescriptive requirements of doing the same things for every two years. Is that a reference to the language on page? Well, I don't know if it's the right page, I have it printed out in a certain way, but in the very last section, we're section two of the continuing education requirements where it lists A through D. Yes. Okay, okay, because it seems that they're fairly broad in description so that I'm not sure I would share your analysis that it would be a repetitive every two year, same. I think, and perhaps the words could be, the language could be more broadly worded so that it allowed for the innovative and refreshing information for those who had already completed some previously, but I want to make sure I understood where that reference was coming from. Representative Sheena and Representative Goldman. Go ahead, Brian. I just wanted to say something related to what we were just talking about with interpretation. One thing that I heard you say, this is to our witnesses, one thing that I heard you say is that one of the considerations for providers about using interpretation might be cost. Another thing that I've experienced, and I'm curious if you could speak to is sometimes it's not cost, it's actually patient preference because in a small community, people know each other and sometimes a patient's like, I don't want that to be my interpreter and then you don't have an interpreter because they're refusing to work with the interpreter who's available or you want to use like teleinterpreters and they don't want you to use teleinterpreters because they don't know the person. So it's like either they know the person, they don't know the person and some families they want it to be private, they want it to be a family member. In other situations, it's not that. People do want help, but they're afraid to ask for something different. So I think ultimately, when we talk about cultural competency training, we're talking about better understanding how to work with people and not making assumptions based on someone's culture, but figuring out how do you figure out the needs of an individual and meet them where they're at. And so that being said, do you have any more thoughts around, specifics that we would put into the language around the training requirements or what we'd be looking at besides just cultural competency or anti-racism? Is there any other direction you'd have? But if not right now, maybe that's something you could think about. I'd be happy to think about it. I would love to provide input on language if you're open to that or interested in that. I think you could add to the list of topics. I apologize, I don't have the bill in front of me, the language in front of me right now. I believe the language is focused on cultural competence. You could spell out specifically that the group should look at training around language and interpretation services as well. I don't know if everyone defines that as part of anti-racism and cultural competence training. I don't know if that's inherently part of that definition or not. But I agree with all your points. Yes, we hear those concerns as well. I believe it's been a little while since I've looked at this that while using a family member is discouraged if the patient really wants that. I believe you can ethically honor that even though it's in the typical circumstance, not best practice. Thank you, Representative Goldman and Representative Donahue, and we're getting close to our time. So I think that might be as many questions as we can take this morning. Thank you, everyone for comments and testimony. I'd like to take us back to the exam room for a minute. This morning we had an experience of what it's like to communicate with someone through an interpreter. So put yourself now in an exam room and trying to deal with significant medical concerns and problems and operate through an interpreter. It is very challenging. And I believe clinicians really wanna do a good job for those patients. So we need to support those kinds of services, the availability of those services. And if we can attach any kind of financial support for that, I think that would be important. So I'd like to add that to some place if it's where it might be appropriate. Thank you. Thank you, Representative Donahue. Thank you. Yes, I snuck a quick peek at the VMS 2018 statement about addressing bias. And I was pleased to see that it included the breadth of sort of the health disparity and bias issues that the bill addresses with the various groups, although statement may need to be broadened. For instance, LBGTQ issues are not necessarily just sexual orientation, but it did also include disability. You haven't discussed in terms of training issues and whether there is also ongoing efforts around those other communities. We're gonna be hearing more testimony this afternoon, but we had some earlier issues like diagnostic overshadowing with types of disabilities, which is, we know, is a significant health outcome concern. Is that included or any of the pieces of what you're doing? Can I interrupt Representative Donahue? Can you share what your definition of, again, the phrase you just used, overshadowing? Diagnostic overshadowing. Yeah, I think that's a lot. I'm not sure that's in everyone's wheelhouse. I'll briefly, right, I didn't want to testify and it's coming up this afternoon. Oh, I know, but you're using it to ask a question. We don't know what the question means. It's hard to know what the answer is. Yes, I'm sorry to take advantage of the current witness, but that means when, for instance, as an example, a person with a psychiatric diagnosis comes in and that is foremost in the person making a diagnosis mind that's on the medical record. And so to use lay language, the reaction is, well, it must be all in their head because they have a psychiatric diagnosis. And so they're gonna miss or not treat as seriously physical complaints. Thank you. And I bring us back to your question to the witnesses, but I think that's an important clarification. That's a great question. It is certainly an issue that I am aware of, medical specialty societies, for example, addressing through their educational sessions. I know it's been a big topic and even covered in the media around maternal health outcomes, especially BIPOC women, sort of not their post-delivery complaints being, basically dismissed or not appreciated. I'm starting to think back, Jill, maybe, you know, I don't know if it's been addressed in the sessions that we have put on, but I know there are educational sessions again by national organizations on that issue. Jill, do you recall if it's been? Not a speciality issue as opposed to a primary care or other specialty care than mental health. It's the other specialties where the issue. Yes, and so when I say specialty society, I include actually primary care. Is that not just specialists, but the family physicians, the psychiatrists? Jill, any further? Well, I was just gonna say this is an example of how this issue is really evolving. So we're in 2021. We adopted that in 2018. And I learned another term yesterday, the minority stress model. And I think that really captures a lot of the issues. And I will just say that, you know, again, going back to everyone having these implicit biases, one of the things that I, you know, feel like must come up in Vermont is if you have used or you are a current substance, you know, user, what kind of bias do you have, you know, when you walk into your medical home? There's just bias across the board with any diagnosis. You know, when our family members, you know, point out mental health issues, you're like, oh, you don't want a diagnosis because what is that going to mean for you in your future? So, you know, and then just there's the insurance part of that of like preexisting conditions. And so there's all of those layers, I think that you're naming are the concerns that we're attempting to address. I will say the task force, the AAP Vermont is specifically looking at race. And so, but that's only covering like, you know, a small picture of the health equity issues that we have to deal with in our state. So how we get at this is really part of why we're saying, let's not try to do a one size fits all because we really need to understand the breadth and we really need to look at what's specifically going to help our medical professionals give the best care. And I really liked how Zana Davis said yesterday that when we learn how to give culturally appropriate medical care to these, you know, to different communities that have disproportionate poor health outcomes, we're actually raising the level of care for everyone. And we really need to think about that and really underscore that this is where we need to be as a country and COVID has shown us that too. Thank you. Representative Donis here, your hand is still up but I assume that was from previous. Well, again, thank you both, Jess and Jill for joining us this morning. Again, on relatively short notice, but I appreciate you're reaching out actually and saying we would like to be heard. We'd like to testify, so thank you. And I think with that we'll conclude for our testimony this morning.