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Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2023 Jul-.

Cover of Making Healthcare Safer IV

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices [Internet].

Healthcare worker implicit bias training and education.

Julie Fricke , Ph.D., Shazia Mehmood Siddique , M.D., M.S.H.P., Jaya Aysola , M.D., DTMH, M.P.H., Margot E. Cohen , M.D., M.S.Ed., and Nikhil K. Mull , M.D.

Created: January 2024 .

  • Structured Abstract

Objectives:

Evaluate the effectiveness and unintended effects of healthcare worker (HCW) implicit bias training and education interventions on patient safety, health, and healthcare outcomes.

We followed rapid review processes of the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We searched PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library from March 2013 to June 2023, in addition to a narrowly focused search for unpublished reports. We included systematic reviews, randomized controlled trials (RCTs), and observational studies with a comparison group that evaluated HCW implicit bias training and education.

Six primary studies were included (five RCTs and one pre/post study design). No included primary study evaluated HCW implicit bias training and education specifically, but each reported outcomes of interest for related, indirect interventions. One study evaluated cultural sensitivity training versus no training, two evaluated cultural competency training plus feedback versus feedback only, one evaluated communication skills training versus no training, one three-arm study evaluated education versus education plus cross-cultural communication training versus usual care, and one evaluated a communication skills training pre/post implementation. Although four of the six studies found significant improvement in select secondary HCW-related outcomes of interest after training completion, such as cultural awareness, only the pre/post study on communication skills found a significant impact on patient outcomes. Substantial heterogeneity across studies prevented any strength of evidence conclusions.

Conclusions:

Only clinically heterogeneous, indirect evidence of interventions related to implicit bias training were identified for primary outcomes of interest. As no included study evaluated HCW implicit bias training and education specifically, no conclusions could be drawn regarding the impact of the intervention on patient outcomes.

1. Background and Purpose

The Agency for Healthcare Research and Quality (AHRQ) Making Healthcare Safer (MHS) reports consolidate information for healthcare providers, health system administrators, researchers, and government agencies about practices that can improve patient safety across the healthcare system—from hospitals to primary care practices, long-term care facilities, and other healthcare settings. In spring 2023, AHRQ launched its fourth iteration of the MHS Report (MHS IV) .

Implicit bias training as a patient safety practice (PSP) was identified as high priority for inclusion in the MHS IV reports using a modified Delphi technique by a Technical Expert Panel (TEP) that met in December 2022. The TEP included 15 experts in patient safety with representatives of governmental agencies, healthcare stakeholders, clinical specialists, experts in patient safety issues, and a patient/consumer perspective. See the Making Healthcare Safer IV Prioritization Report for additional details. 1

In the context of this review, implicit biases are unconscious attitudes and beliefs that may influence behaviors such as nonverbal communication, healthcare worker (HCW) perceptions and clinical assessments about patients, and decisions about patient management. 2 HCWs are defined broadly as people working in facilities who provide direct care to patients including physicians, nurses, pharmacists, allied healthcare professionals, diagnostic staff, ancillary staff, contracted staff, volunteers, students, and trainees. Implicit biases operate outside of conscious awareness and are often anchored on patient characteristics such as race, ethnicity, and gender. 3 Also, socio-demographic characteristics of HCWs (e.g., gender, race, type of healthcare setting, years of experience) are correlated with level of bias. 4 These biases permeate healthcare and can influence judgment and contribute to discriminatory behavior. 5 , 6 More specifically, HCW implicit bias may lead to inequitable care delivery and poor patient outcomes, perpetuating well-known disparities. 4 For example, a recent systematic review revealed that many HCWs had negative bias toward non-White people, as measured by the Implicit Association Test (IAT), which negatively impacted patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. 7 Indeed, another review found that increased provider racial and ethnic bias, as measured by the IAT, consistently correlated with poorer patient-provider interactions. 8 An additional review also showed that physicians demonstrated an implicit preference for White people, as measured by the IAT, but this bias appeared to influence clinical decision making in only two of the nine qualifying studies. 9 Racial inequities in perinatal care have garnered substantial attention and have motivated efforts to mitigate implicit bias. 10 Addressing implicit bias is a fundamental, professional responsibility of all healthcare institutions and providers. 11 HCW implicit bias training and education PSPs may aid in addressing such bias and its negative consequences.

1.1. Overview of Implicit Bias

HCW implicit bias can impact patient safety through clinical misdiagnosis, pain mismanagement, and lead to other unfavorable patient outcomes. 12 A 2022 RAND report identified reported linkages between implicit bias and patient safety such as underreporting events and shifting blame to vulnerable populations. 13 Training programs for HCWs have arisen to combat implicit bias, with certain states passing legislation mandating implicit bias training for at least some categories of health professionals. 10 Training programs are implemented to equip HCWs with the knowledge and skills needed to prevent biases from influencing the quality of care that they provide. 14 Evidence for implicit bias training is evolving and approaches are widely heterogeneous. Implicit bias training can vary by content and learning objectives. Common objectives of training are to improve HCW awareness, recognition, and management of implicit bias through strategies such as critical reflection, perspective-taking, counter-stereotyping, and skills and knowledge-building. 15 Training can also vary by format (e.g., workshop, academic course), delivery method (e.g., in-person, web-based, in groups), frequency, or length, among other characteristics. It may focus on certain clinical areas or patient populations or take a “one-size-fits-all” approach. Further, it may be provided at any point in the HCW career, from students in degree programs, postgraduate trainees, to seasoned staff, and can be administered in clinical or nonclinical settings. To date, implicit bias training is often evaluated through pre-post surveys or standardized assessments that measure changes in HCW outcomes (e.g., attitudes and beliefs) and is rarely linked to patient health and safety. Implicit bias training that recognizes differential risks of patient safety in marginalized patient groups will be prioritized in this review.

The MHS III report noted that more can be done to explore the link between adverse safety events and provider bias and/or racism. According to the report, several studies show a link between providers’ implicit bias and patient communication challenges, as well as healthcare and health outcomes. 4 , 7

In the prioritization process, the Making Healthcare Safer IV TEP noted that the PSP was defined to focus on implicit bias training to recognize differential risks of patient safety events in marginalized groups, but the topic could be expanded to include the role of implicit bias in PSPs more generally. As there are several high-quality, recent systematic reviews that evaluate the impact of HCW implicit bias, this review focuses on the effect of HCW implicit bias training specifically and uses previous related systematic reviews to supplement our findings.

1.2. Purpose of the Rapid Review

The purpose of this review is to determine the effect of HCW implicit bias training and education interventions on key patient and HCW outcomes, including health and healthcare disparities, healthcare-acquired conditions, access to healthcare, healthcare utilization, diagnostic error, mortality, quality (e.g., patient satisfaction), adverse effects (e.g., HCW burnout and satisfaction) and unintended consequences (e.g., health and healthcare disparities in other populations) and how these interventions may be implemented.

1.3. Review Questions

  • What are the frequency and severity of harms associated with HCW implicit bias?
  • What patient safety measures or indicators have been used to examine the harm associated with HCW implicit bias?
  • What training- and education-related PSPs have been used to prevent or mitigate the harms associated with HCW implicit bias and in what settings have they been used?
  • What is the rationale for PSPs related to HCW implicit bias training and education used to prevent or mitigate the harms?
  • What are the effectiveness and unintended effects of HCW implicit bias training and education PSPs?
  • What are common barriers and facilitators to implementing HCW implicit bias training and education PSPs?
  • What resources (e.g., cost, staff, time) are required for implementation of HCW implicit bias training and education PSPs?
  • What toolkits are available to support implementation of HCW implicit bias training and education PSPs?

For this rapid review, strategic adjustments were made to streamline traditional systematic review processes. We followed adjustments and streamlining processes proposed by the AHRQ Evidence-based Practice Center (EPC) Program. Adjustments included being as specific as possible about the questions, limiting the number of databases searched, modifying search strategies to focus on finding the most valuable studies (i.e., being flexible on sensitivity to increase the specificity of the search), and restricting the search to studies published recently in English and performed in the United States, and having each study’s eligibility assessed by a single reviewer. A randomly selected 10 percent sample of excluded citations were checked by a second reviewer. This review focused on HCW training and education PSPs to evaluate the effect on various targeted harms of implicit bias.

We searched for recent high quality systematic reviews and relied heavily on the findings of any such systematic reviews that were found. We did not perform an independent assessment of original studies cited in any such systematic review.

We answered Review Questions 1 and 2 by focusing on the harms and patient safety measures or indicators that are addressed in the studies we found for Review Question 5. For Review Question 2, we additionally focused on identifying relevant measures that are included in the Centers for Medicare & Medicaid Services (CMS) patient safety measures, AHRQ’s Patient Safety Indicators, or the National Committee for Quality Assurance (NCQA) patient safety related measures.

We asked our content experts to answer Review Questions 3 and 4 by citing selected references, including PSPs used and explanations of the rationale presented in the studies we found for Review Question 5.

For Review Questions 6 and 7, we focused on the barriers, facilitators, and required resources reported in the studies we found for Review Question 5.

For Review Question 8, we identified publicly available patient safety toolkits developed by AHRQ or other organizations that could help to support implementation of the PSPs. To accomplish that task, we reviewed AHRQ’s listing of patient safety related toolkits (see https://www.ahrq.gov/tools/index.html?search_api_views_fulltext=&field_toolkit_topics=14170&sort_by=title&sort_order=ASC ) and we included any toolkits mentioned in the studies we found for Review Questions 5–7. We identified toolkits without assessing or endorsing them.

The protocol for this review was registered with PROSPERO (CRD42023456865).

2.1. Eligibility Criteria for Studies of Effectiveness

We searched for original studies and systematic reviews on Review Question 5 according to the inclusion and exclusion criteria presented in Table 1 . There were no specific inclusion or exclusion criteria applied to other review questions other than processes for identifying information noted in the methods.

Inclusion and exclusion criteria.

2.2. Literature Searches for Studies of Effectiveness

Our search strategy focused on biomedical databases expected to have the highest yield of relevant studies, including PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The main search was supplemented by a narrowly focused search for unpublished reports that are publicly available from governmental agencies or professional societies with a strong interest in the topic, including the Association of American Medical Colleges (AAMC), Accreditation Council for Graduate Medical Education (ACGME), Centers for Disease Control and Prevention (CDC), AHRQ, the National Institutes of Health (NIH), National Quality Forum (NQF), and American Hospital Association (AHA). All searches were limited to March 31, 2013, to June 2023, which represents the time since searches were completed by a comprehensive systematic review addressing the prevalence and impact of implicit bias among HCWs. 4 For details of the search strategy, see Appendix A .

2.3. Data Extraction (Selecting and Coding)

To efficiently identify studies that meet eligibility criteria, each citation was reviewed by a single team member. A second team member checked a 10 percent sample of excluded citations to verify that important studies were not excluded after the review of titles and abstracts. The full text of each remaining potentially eligible article was similarly reviewed by a single team member to confirm eligibility and extract data. Studies within relevant reviews were also assessed for eligibility. A second team member checked a randomly selected 10 percent sample of excluded full text citations to verify that important studies were not excluded and confirm the accuracy of extracted data. Because no studies were identified that evaluated HCW implicit bias training specifically, indirect studies of related interventions were included that may not have met all portions of the eligibility criteria (e.g., setting/country, participant number, interventions with indirect educational content).

Information was organized according to the review questions: frequency, and severity of the harms (question 1), measures of harm (question 2), characteristics of the PSP (question 3), rationale for the PSP (question 4), outcomes (question 5), implementation barriers and facilitators (question 6), resources needed for implementation (question 7), and description of toolkits (question 8).

2.4. Risk of Bias (Quality) Assessment

No original risk of bias assessment was conducted. The quality of the included primary studies was evaluated previously within the included reviews (sometimes more than once across reviews) using various tools. The results of those assessments are reported in Table 3 .

2.5. Strategy for Data Synthesis

The evidence was synthesized narratively for each Review Question. No meta-analysis was conducted given the small number of included studies and diverse outcomes reported. Strength of evidence assessment was not performed based on the lack of available direct evidence and heterogeneity across included studies evaluating indirect interventions.

3. Evidence Summary

3.1. benefits and harms.

  • Five of the six studies included primary care physicians (one of which also included nurse practitioners and physician assistants).
  • Two studies included patients with diabetes and/or hypertension, one included only patients with type 2 diabetes, one included only patients with hypertension, one included pediatric patients with persistent asthma, and one included patients receiving home and hospital care (diagnoses not reported).
  • The most frequently reported primary outcomes were changes in patient hemoglobin A1C (HbA1c) and blood pressure.
  • None of the six studies were considered low risk of bias, as determined by previous reviews.
  • No included studies evaluated HCW implicit bias training and education specifically; as such, no conclusions could be drawn about the benefits and harms of this intervention.
  • Facilitators to implementation of HCW implicit bias training and education cited included interventions based on theoretical frameworks for both implicit bias content and educational curricula. Barriers primarily identified resource constraints including time allotted for education, training and expertise of educational facilitators, and institutional and financial support.
  • Forms of culturally focused training have been shown to improve HCW attitudes, beliefs, skills, and behaviors, but how these improvements translate to changes in disparities and patient health and safety outcomes is unclear.

3.2. Future Research Needs

  • High quality trials that evaluate the longitudinal impact of theory-based HCW implicit bias training and education on patient health and safety outcomes.
  • Research to help determine optimal education frameworks and training, reproducible strategies, and the effective cadence and frequency of such training.
  • Toolkits for implementation with demonstrated effectiveness for HCW implicit bias training and related quality measure development to improve patient safety.

4. Evidence Base

4.1. number of studies.

Our searches retrieved 1,217 unique titles and abstracts from which we screened 261 full text articles for eligibility ( Figure 1 ). No studies were identified that evaluated implicit bias training and education specifically; however, seven reviews and one primary study were identified that evaluated indirect but related interventions. After assessing the included studies within those seven reviews for eligibility, only five primary studies were relevant to this review, resulting in six included primary studies total. A list of excluded studies can be found in Appendix B . Almost all studies that were excluded at full-text screening lacked relevant outcomes.

Results of search and screening.

4.2. Findings for Review Questions

4.2.1. question 1: what are the frequency and severity of harms associated with hcw implicit bias.

HCW implicit bias can lead to inequitable care delivery, including clinical misdiagnosis and pain mismanagement, and lead to other unfavorable patient outcomes, perpetuating well-known disparities. 4 , 12 A recent systematic review on implicit bias in HCWs reported that 35 of the 42 included studies found evidence of implicit bias in HCWs and every study that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care. 4 Indeed, another recent review revealed that many HCWs had negative bias toward non-White people, as measured by the Implicit Association Test (IAT), which negatively impacted patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. 7 Similarly, another review found that increased provider racial and ethnic bias, as measured by the IAT, consistently correlated with poorer patient-provider interactions. 8 An additional review also showed that physicians demonstrated an implicit preference for White people, as measured by the IAT, but this bias appeared to influence clinical decision-making in only two of the nine qualifying studies. 9

4.2.2. Question 2: What Patient Safety Measures or Indicators Have Been Used To Examine the Harm Associated With HCW Implicit Bias?

There are currently no existing CMS, AHRQ, NCQA patient safety measures or indicators examining the harm associated with HCW implicit bias. 16 – 18 However, the CMS Innovation Center 2022 Strategic Plan calls for advancing health equity with plans to tackle implicit bias, specifically relating to algorithmic bias. As part of this effort, CMS has moved to modify known biased algorithms to determine beneficiary eligibility including estimated glomerular filtration rate (eGFR), comprehensive joint replacement model, and the Million Hearts ® Model. 19 While these efforts do not directly address HCW implicit bias or related training, they encourage clinicians to adopt more equitable algorithms used in their health system. Similarly, select NCWA measures aim to standardize care and track utilization for vulnerable populations, including patients with alcohol and other drug abuse or dependence and individuals with mental health conditions. 17 Such standardization of care through more equitable algorithms and measured focused on marginalized patient populations may indirectly effect HCW implicit bias.

4.2.3. Question 3: What Training- and Education-Related PSPs Have Been Used To Prevent or Mitigate the Harms Associated With HCW Implicit Bias and in What Settings Have They Been Used?

Our search did not find any studies specifically addressing HCW implicit bias training and education effects on patient health and safety outcomes. One review article has explored educational strategies in health professions trainees to mitigate the effects of implicit bias, the majority of which focus on medical students. 20 The focus of this review was on the role of educational interventions to reduce to influence of implicit bias on clinicians’ decision making. Only eight studies were identified in this review article, most of which did not use an underlying conceptual framework. Racial implicit bias was the most common, followed by general implicit bias and weight-based implicit bias. A variety of educational approaches were used, many of which included only a single synchronous session or flipped classroom approach, and few used real-world environments that would be applicable to practicing healthcare workers. A wide variety of educational techniques were employed with the most common being group discussion, readings, critical reflection, and use of the IAT. Assessment strategies were varied and not applicable to practicing healthcare workers. Notably, for future research related to bias and equity initiatives it is important that conceptual frameworks be included in study development and publication to improve the quality of scholarship in this realm.

Another systematic review similarly found a lack of studies in practicing healthcare workers, with the few existing studies failing to adequately describe educational approaches or outcomes relevant to clinical care or patient safety. 21 Studies have shown participant reflection and changes in self-awareness of implicit bias. In health professions education, the IAT has been used as a tool to raise awareness of existing implicit bias and to assess efficacy of educational interventions. 6

Notably, in 2018, Sukhera et al. 22 proposed a six-point framework for integrating implicit bias training into health professions education. This framework includes the following considerations: “creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others.” This framework may help institutions or health systems that wish to incorporate more implicit bias training into their curricula or faculty development approaches.

A narrative review underscores prior evidence findings that contemporary approaches to teaching cultural competence and minority health are generally insufficient to reduce implicit bias among HCWs. 23 A study found that implicit prejudice and stereotyping is present when students begin training in healthcare, and that the level of implicit bias remains constant or increases as students matriculate through their training. 24 Another study found significant increases in medical students’ disparate behaviors toward Black standardized patients between their first and second years of medical school. 25 Similar results stemmed from the analysis of data from The Cognitive Habits and Growth Evaluation Study (CHANGES) project. 26 The CHANGES project was a 4-year longitudinal study that tracked implicit and explicit bias among 3959 students across 49 medical schools in the United States. Analyzing CHANGES data, Phelan and colleagues 26 found that whereas implicit bias toward obese patients remained constant, explicit bias increased during the 4 years of medical school. Also using the CHANGES dataset, van Ryn and colleagues 27 identified several informal factors that predicted increases in implicit bias during medical school, such as hearing negative comments from supervising medical attendings about Non-Hispanic Black/African American (AA) patients or having minimal interactions with Black/AA medical students or attending physicians. The van Ryn paper 27 reported that several formal trainings, such as courses, workshops, and seminars on cultural competence, minority health, and racial healthcare disparities, resulted in small but significant associations with reductions in implicit bias during medical school; however, these effects were eliminated after controlling for other formal training exposures and baseline implicit bias tests. Of the formal curricula variables, having taken an IAT as part of medical school training and self-efficacy regarding care for African American patients persisted in their statistically significant association with reductions in implicit bias. This evidence on both formal interventions as well as the role of hidden curriculum and exposure to diversity in educational settings is useful to guide training efforts to help mitigate bias in clinical settings.

4.2.4. Question 4: What Is the Rationale for PSPs Related to HCW Implicit Bias Training and Education Used To Prevent or Mitigate the Harms?

Our search did not find any studies specifically addressing HCW implicit bias training and education with an eye toward patient safety outcomes. However, multiple strategies have been considered to reduce HCW implicit bias, including increasing awareness of implicit biases and attempts to encourage behavior change. 28

Most educational interventions designed to reduce implicit bias use a two-step approach that includes (1) making students aware of their implicit biases or self-reflection activities, and (2) providing instruction on strategies they can use to either reduce the activation of implicit associations or control how those associations influence judgment and behavior. 23 , 27 , 29 – 32 Most training workshops with HCWs begin with self-reflection activities as a common educational tool for helping HCWs become aware of bias. 32 However, evidence suggests that awareness, by itself, is insufficient to change HCW perceptions, attitudes, or behaviors toward stigmatized patient groups. 24

Control strategies focus on instructing HCWs in managing their automatic responses to stigmatized patients, such as affirming egalitarian goals, seeking common-group identities, perspective-taking, and individuation via counter-stereotyping. 29 – 31 One study by Lai and colleagues 33 compares these strategies and suggests that seeking counter-stereotypic and common-identity information (e.g., shifting group affiliations or boundaries) may be especially effective for reducing implicit bias among a non-healthcare worker sample. Instruction in perspective-taking strategies shows positive effects on implicit bias among HCWs. 34 Blatt et al. 35 demonstrated that a perspective-taking intervention with medical students improved African American/Non-Hispanic Black patient satisfaction relative to the control training.

Several studies have shown the benefit of combining the strategies above in a singular training or educational activity. 36 Two-step training programs that raise awareness and thereafter provide control strategies have demonstrated changes in HCW biases. 37

It remains unclear which strategies, either in isolation or combination, work best for reducing implicit bias in patient care. The strategies above are assessed as educational interventions without addressing the patient-facing outcomes of HCW implicit bias. Nevertheless, integrating implicit bias education into existing healthcare training appears necessary to address the role that HCW bias may play in creating disparities in patient outcomes.

4.2.5. Question 5: What Are the Effectiveness and Unintended Effects of HCW Implicit Bias Training and Education PSPs?

No studies were identified that evaluated implicit bias training and education specifically. Seven reviews 38 – 44 and one primary study 45 were identified that evaluated indirect but related interventions. After assessing the included studies within those seven reviews for eligibility, only five primary studies were relevant to this review, resulting in six included primary studies total ( Table 2 ). 45 – 50 Other primary studies from the identified reviews were excluded primarily based on outcomes.

Five of the six studies were RCTs and one was mixed methods pre/post study. 50 One study evaluated cultural sensitivity training versus no training, 46 two studies evaluated cultural competency training plus feedback versus feedback only, 47 , 48 one study evaluated communication skills training versus no training, 49 one three-arm study evaluated education versus education plus cross-cultural communication training versus usual care, 45 and one studied evaluated a communication skills training pre/post implementation. 50 The evidence from these studies is indirectly applicable to implicit bias training. Five of the studies focused on training for primary care physicians (one of which also included nurse practitioners and physician assistants), 48 while one study focused on training for nurses and homecare workers. 46 Two studies included patients with diabetes and/or hypertension, 47 , 50 one included only patients with type 2 diabetes, 48 one included only patients with hypertension, 49 one included pediatric patients with persistent asthma, and one included patients receiving home and hospital care (diagnoses not reported). 46 Although there was some similarity across studies for patient outcomes reported (e.g., HbA1c, blood pressure), the training focus and content provided in each study varied widely. The substantial heterogeneity across studies prevented any strength of evidence conclusions. Notably, only three of the six studies 45 , 49 , 50 were conducted in the last 10 years.

Primary study characteristics.

Although four of the six studies reported significant improvement in select HCW-related outcomes of interest after training completion, 45 , 46 , 48 , 50 (e.g., understanding, awareness, confidence, and communication ability), only one study reported a significant impact of training on patient health outcomes 50 ( Table 3 ). Specifically, a culturally sensitive communication training that used a guideline (tailored to the Southeast Asian context) plus feedback for primary care doctors was found to significantly decrease blood pressure or fasting blood glucose levels six weeks post implementation (p<0.05) among patients with hypertension or diabetes in Indonesia. 50 The quality of this pre/post study was assessed in one of the included reviews 41 using the ROBINS-I tool and was considered to have “Some Concerns.” The authors observed potential confounding of post-intervention blood glucose outcomes (e.g., meals were not standardized prior to data collection) and some risk of social desirability bias related to measures of patient perceptions of doctors’ communication attitudes. The other five studies evaluating cultural sensitivity, cultural competency, or cross-cultural communication training showed no impact on patient health outcomes of interest. Each of those five RCTs were also appraised in at least one of the included reviews. None were considered low risk of bias. As no study evaluated HCW implicit bias training and education specifically, no conclusions could be drawn about the impact of this intervention on patient outcomes.

Primary study results and quality.

4.2.6. Question 6: What Are Common Barriers and Facilitators to Implementing HCW Implicit Bias Training and Education PSPs?

As no eligible studies specific to implicit bias training effects on eligible outcomes were identified, there was no information on barriers and facilitators to effective implementation. However, several studies excluded for eligibility in Review Question 5 were identified during citation screening that described effective strategies for to implementation of implicit bias training PSPs for HCWs and may provide useful context as potential facilitators and barriers.

Education focusing on implicit bias recognition and management skills development was proposed to be conceptually more effective than de-biasing and awareness education in a 2023 scoping review of implicit bias curricular interventions. 51 Specifically, use of transformative learning theory has been postulated to be an effective educational theory framework for delivering implicit bias training. 6 , 51 While no eligible studies were identified that used skills-based practice and development interventions in clinical settings, multiple aspects of curricula were identified that can be used for the basis of more advanced curriculum implementation to assess theoretic frameworks for educationally sensitive patient outcomes. Use of objective assessment and construct validity of assessment tool was seen in nine (out of 51) studies, several measured assessment 16 weeks or greater post-intervention (n=5/51 studies) compared with immediately after the education, five studies implemented seven or more training sessions in series for learners to achieve greater sustainability, and seven studies described implicit bias training programs that targeted more than one target group of bias (e.g., race, ethnicity, gender, religion). In another scoping review, group discussion format was most frequently cited (26%, n=9/35 studies) as a facilitator and an aspect of strength for educational formats. 52 A 2022 review examining the effect of educational interventions for both explicit and implicit bias similarly found that the majority of interventions (68%, n=17/25 studies) were able to use interactive formats including classroom and web-based sessions. 6

Resource availability is frequently cited as a common barrier to implementation of implicit bias training for HCW. A 2022 scoping review characterizing the educational curricula used in implicit bias training interventions of post-graduate physicians found that most studies (53%, n=19/36) cited resource limitations, including time and scheduling, training, financial and institutional support as the most common barriers to implementation of implicit bias training. 52 Over half of the described interventions included only one education session due to scheduling and time constraints of the learners. The 2023 scoping review similarly noted that most studies described implicit bias training programs that were single-session only, used self-assessment rather than objective, validated assessment post-training, measured effects of training to the immediate post-intervention period and instead of longitudinally, and focused on a single area of bias rather than training for multiple biases or implicit bias in general. 51 These limitations reflect commonly cited barriers to implementation of implicit bias training programs. No implicit or explicit bias training interventions included clinical settings in the Vela 2022 review, pointing to the pragmatic challenges of such study designs in the previous literature. 6 A third identified scoping review described implicit bias educational interventions specific to health professional trainees or students with notable findings of heterogeneous and limited interventions. 53 They noted most identified studies lacked an implicit bias content framework (39%, n=11/28 studies), lacked an educational curricular framework (36%, n=10/28 studies), lacked implicit bias learning objectives (43%, n=12/28 studies), and were delivered to a single discipline (78%, n=22/28 studies). Also, only a handful of studies were described for nursing (7%, n=2/28 studies), pharmacy (4%, n=1/28 studies), or allied health sciences fields (4%, n=1/28 studies).

4.2.7. Question 7: What Resources (e.g., Cost, Staff, Time) Are Required for Implementation HCW Implicit Bias Training and Education PSPs?

No information was identified to quantify costs, personnel, time, or related resources required to implement HCW implicit bias training. As these may be highly contextual and heterogeneous depending on setting, learner, and infrastructure, information is provided in this section on criteria or other recommendations for necessary components to implicit bias training for HCWs.

Recommended criteria to develop effective implicit bias training interventions for HCWs have been described, including resources required. These include formal curriculum development training of educational leads, mandate inclusion in required aspects of training curricula, knowledge, and assessment of evidence-based curriculum design by educators, utilizing patient simulation to practice skills-based development, and objective assessment of skills using validated tools. Resistance to education and assessment was experienced in significant minority of participants exposed to implicit bias education, leading authors to recommend use of trained facilitators, instruction on the assessment tool itself, debriefing strategies, and dedicated instruction on management strategies. 6 A qualitative study of medical students’ views on challenges and opportunities in racial and ethnic implicit bias instruction revealed common themes including questioning the presence of bias within themselves, utility of the IAT, and the influence of implicit bias on clinical outcomes. 54 Resistance to implicit bias education from this study also noted that bias is immutable and learned at an early age and that education in implicit bias is common sense, intuitive, and unnecessary.

The 2022 systematic review by Vela et al. examining explicit and implicit bias noted that effects on sustained patient health outcomes were lacking across all health disciplines and all levels of training. 6 Authors of this review suggested that implicit bias training alone is likely insufficient to improve outcomes, but would need to be paired with efforts to eliminate barriers such as structural inequities and need for increased diversity of HCWs. 6

In the previously described 2023 scoping review, financial support for implicit bias curricula were secured through various mechanisms and agencies for 18 of 51 described studies, including five which received institutional funding. 51 Level of funding or other financial parameters were not reported.

4.2.8. Question 8: What Toolkits Are Available To Support Implementation of HCW Implicit Bias Training and Education PSPs?

  • A Framework for Integrating Implicit Bias Recognition Into Health Professions Education 22
  • Implicit Bias in Health Professions: From Recognition to Transformation 55
  • Addressing Biases in Patient Care with The 5Rs of Cultural Humility, a Clinician Coaching Tool 56
  • Twelve tips for teaching implicit bias recognition and management 15
  • I’m Biased and So Are You. What Should Organizations Do? A Review of Organizational Implicit-Bias Training Programs 57
  • Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias 58
  • Confidence, Connection & Collaboration: Creating a Scalable Bias Reduction Improvement Coaching Train-the-Trainer Program to Mitigate Implicit Bias across a Medical Center 59
  • Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development 60

5. Discussion

5.1. summary and interpretation of findings.

This review sought to understand what we know about the impact of implicit bias training and education on key patient and provider outcomes and the feasibility and issues around implementation of such trainings. There is currently no published research on the effectiveness of implicit bias training and education specifically, but six primary studies (five RCTs and one pre/post study) that evaluated related, indirect interventions were identified and included. One study evaluated cultural sensitivity training versus no training, two evaluated cultural competency training plus feedback versus feedback only, one evaluated communication skills training versus no training, one three-arm study evaluated education versus education plus cross-cultural communication training versus usual care, and one evaluated a communication skills training pre/post implementation.

Although four of the six studies found significant improvement in select secondary HCW-related outcomes of interest after training completion, such as cultural awareness, only the pre/post study on communication skills found a significant impact on patient health outcomes. Specifically, a culturally sensitive communication training that used a guideline plus feedback for primary care doctors was found to significantly reduce blood pressure or fasting blood glucose levels 6 weeks post implementation among patients with diabetes or hypertension, respectively, in Indonesia. 50 Substantial heterogeneity across studies prevented any strength of evidence conclusions. None of the six studies were considered low risk of bias.

With only one of six studies reporting any significant effect on patient health outcomes, and previous work suggesting flaws in current educational strategies for HCWs, 20 , 51 , 52 more rigorous approaches may be needed. Generally, forms of culturally focused training have been shown to improve HCW attitudes, awareness, skills, and behaviors, 38 , 39 , 41 but how these improvements translate to changes in disparities and patient health and safety outcomes needs further investigation.

5.2. Limitations

All searches were limited to 2013 to present which restricts the amount of evidence included, but the cut-off was thoughtfully chosen, as it represents the time since searches were completed by a comprehensive systematic review addressing the prevalence and impact of implicit bias among HCWs. 4 Further, no included study evaluated implicit bias training and education specifically; therefore, only indirect evidence that may not have met all inclusion criteria was discussed. Although related to implicit bias, cultural competency (and other communication skills) are separate constructs. None of the included primary studies were considered low risk of bias, as determined by the review authors. Also, as this was a rapid review, screening and extraction was conducted by a single reviewer. However, a second team member checked a 10 percent sample of excluded citations at both the title/abstract and full-text stage to verify that important studies were not excluded and confirm accuracy of the data.

5.3. Implications for Clinical Practice and Future Research

As no included study evaluated HCW implicit bias training and education specifically, no conclusions could be drawn on the effectiveness of the intervention on patient outcomes. High quality, pragmatic randomized or other controlled comparative effectiveness trials conducted in real-world clinical settings are needed to evaluate the longitudinal impact of theory-based HCW implicit bias training and education on patient health and safety outcomes. As previously noted in the 2022 RAND report on the linkage between patient safety and implicit bias, evidence on causality is available but limited and frequently reported in editorial and commentary forms and further empirical evidence is needed related to implicit bias, HCW training, and patient safety. Further, research should aim to determine optimal education frameworks and training, reproducible strategies, and the effective cadence and frequency of such training. Finally, there is a need for toolkits for implementation with demonstrated effectiveness for HCW implicit bias training and related quality measure development to improve patient safety.

6. References

  • Acknowledgments

The authors gratefully acknowledge the following individuals for their contributions to this project: Kamila Mistry, Ph.D., M.P.H., Deputy Director, Office of Extramural Research, Education and Priority Populations at AHRQ; Laura Koepfler, M.L.S., Helen Dunn, Katherine Donohue, and Britney Hall for references and editorial support; and Jesse M. Munn, M.B.A., Jonathan R Treadwell, Ph.D., and Brian F. Leas, M.S., for oversight and management support.

  • Peer Reviewers
  • Cristina M. Gonzalez, M.D., M.Ed. Professor of Medicine and Population Health New York University Grossman School of Medicine Institute for Excellence in Health Equity New York University Langone Health New York, NY
  • Monica Vela, M.D., FACP Professor of Medicine University of Illinois College of Medicine Chicago, IL

Recognized for excellence in conducting comprehensive systematic reviews, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program is developing a range of rapid evidence products to assist end-users in making specific decisions in a limited timeframe. AHRQ recognizes that people are struggling with urgent questions on how to make healthcare safer. AHRQ is using this rapid format for the fourth edition of its Making Healthcare Safer series of reports, produced by the EPC Program and the General Patient Safety Program. To shorten timelines, reviewers make strategic choices about which processes to abridge. However, the adaptations made for expediency may limit the certainty and generalizability of the findings from the review, particularly in areas with a large literature base. Transparent reporting of the methods used and the resulting limitations of the evidence synthesis are extremely important.

AHRQ expects that these rapid evidence products will be helpful to health plans, providers, purchasers, government programs, and the healthcare system as a whole. Transparency and stakeholder input are essential to AHRQ. If you have comments related to this report, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to vog.shh.qrha@SHM .

  • Robert Otto Valdez, Ph.D., M.H.S.A. Director Agency for Healthcare Research and Quality
  • Therese Miller, D.P.H. Director Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality
  • Christine Chang, M.D., M.P.H. Acting Director Evidence-based Practice Center Program Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality
  • David W. Niebuhr, M.D., M.P.H., M.Sc. Evidence-based Practice Center Program Liaison Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality
  • Craig A. Umscheid, M.D., M.S. Director Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality
  • Margie Shofer, B.S.N., M.B.A. Director, General Patient Safety Program Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality
  • Jennifer Eskandari Task Order Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality
  • Farzana Samad, Pharm.D., FISMP, CPPS Health Scientist Administrator Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality

Appendix A. Methods

Search strategies for published literature, table a-1 pubmed search strategy (includes cochrane database of systematic reviews).

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Table A-2 Embase.com search strategy

Table a-3 cinahl search strategy, table a-4 psycinfo search strategy, appendix b. list of excluded studies upon full-text review.

Disclaimers : This report is based on research conducted by the Johns Hopkins University under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, M.D. (Contract No. 75Q80120D00003). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report. The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (research, clinical or patient education, quality improvement projects) in the United States and do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for sale, incorporation into software, incorporation into for-profit training courses) or for use outside of the United States. If organizational policies require permission to adapt or use these materials, AHRQ will provide such permission in writing. AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied. A representative from AHRQ served as a Contracting Officer’s Representative and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis, interpretation of data, or preparation or drafting of this report. AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Healthcare Worker Implicit Bias Training and Education: A Rapid Evidence Review, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).

Fricke J, Siddique SM, Aysola J, Cohen ME, Mull NK. Healthcare Worker Implicit Bias Training and Education: A Rapid Evidence Review (Prepared by the ECRI-Penn Medicine AHRQ Evidence-based Practice Center under Contract No. 75Q80120D00003). AHRQ Publication No. 23(24)-EHC019-9. Rockville, MD: Agency for Healthcare Research and Quality. January 2024. DOI: https://doi.org/ 10.23970/AHRQEPC_MHS4BIAS . Posted final reports are located on the Effective Health Care Program search page .

  • Cite this Page Fricke J, Siddique SM, Aysola J, et al. Healthcare Worker Implicit Bias Training and Education: Rapid Review. 2024 Jan. In: Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2023 Jul-.
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Regal splendor: The Monastery Cathedral of St. Dimitry in Rostov

Rostov. Savior-St. Yakov-St. Dimitry Monastery.  View from southwest corner of monastery wall. From left: Cathedral of St. Dimitry of Rostov, Church of St. Yakov, Conception of St. Anne Cathedral. July 7, 2019

Rostov. Savior-St. Yakov-St. Dimitry Monastery. View from southwest corner of monastery wall. From left: Cathedral of St. Dimitry of Rostov, Church of St. Yakov, Conception of St. Anne Cathedral. July 7, 2019

Located some 130 miles northeast of Moscow, the town of Rostov Veliky rises from the north shore of Lake Nero like a medieval vision. In summer 1911, the Russian chemist and photographer Sergei Prokudin-Gorsky traveled to the town to take images of its domes and towers.          

Rostov is one of the earliest historically attested towns in Russia, first mentioned under the year 862 in the ancient chronicle "Tale of Bygone Years." In 988, Prince Vladimir of Kiev, the Christianizer of Russia, gave the Rostov lands to one of his sons, Yaroslav, a major figure who subsequently became known as "the Wise."

St. Dimitry Monastery, northwest view. From left: Bell tower, St. Dimitry Cathedral, Conception of St. Anne Cathedral, North Gate. Summer 1911

St. Dimitry Monastery, northwest view. From left: Bell tower, St. Dimitry Cathedral, Conception of St. Anne Cathedral, North Gate. Summer 1911

By the middle of the 11 th century, the Rostov lands had passed to Yaroslav's son Vsevolod, and Christian missionaries such as Leonty of Rostov arrived to convert a largely pagan population. For his efforts, Bishop Leonty was martyred in the early 1070s.

Site of religious learning and missionary activity

Following the Mongol invasion (1237-40), during a period of widespread devastation, Rostov gained importance through its church institutions. By the 14 th century, Rostov had become a center of religious learning and missionary activity, producing such pioneers as St. Stephan of Perm and Epiphanius the Wise.

St. Dimitry Cathedral, southwest view. August 5, 1995

St. Dimitry Cathedral, southwest view. August 5, 1995

Perhaps the most revered site among those photographed in Rostov was the Savior-St. Yakov-St. Dimitry Monastery, located on Lake Nero at the western edge of town. Prokudin-Gorsky took several views of the monastery, including the grand church dedicated to St. Dimitry of Rostov. From the time of Catherine II (the Great), the monastery was visited by every emperor except Alexander III, as well as numerous other members of the royal family.          

This monastic retreat was founded apparently in 1389 by one Yakov, a Rostov bishop about whom little is known. Traditional accounts state that he withdrew to a site on Lake Nero near the Archangel Michael Church, which was founded by Bishop Leonty in the mid-11th century. There he built a log church dedicated to the Conception of St. Anne.         

St. Dimitry Cathedral, northwest view. July 7, 2019

St. Dimitry Cathedral, northwest view. July 7, 2019

After Yakov’s death in November 1392, his venerated remains were buried at the Conception Church. In the late 1540s, he was canonized at the Orthodox Church convocations organized by Moscow’s Metropolitan Macarius to recognize Russian saints.          

During the first centuries of its existence, the monastery was known as Conception- St. Yakov. Its earliest masonry structure, the Cathedral of the Conception of St. Anne (originally Trinity Cathedral), arose in 1686 on the site of the wooden Conception Church where St. Yakov was buried.

During the 18 th century, the monastery experienced unprecedented expansion beginning with the arrival in 1702 of Metropolitan Dimitry Tuptalo (1651-1709), a Ukrainian prelate designated by Tsar Peter I (the Great) to the position of Metropolitan of Rostov. Indeed, Dimitry became one of the most prominent church prelates during Peter’s reign. His burial in the Trinity (Conception) Cathedral in 1709 laid the foundation for the monastery’s elevation.        

St. Dimitry Cathedral, northwest view at sunset. July 7, 2019

St. Dimitry Cathedral, northwest view at sunset. July 7, 2019

Dimitry’s remains were uncovered during a repair of the Trinity Cathedral floor in 1752. Two years later, the cathedral was rededicated to the Conception of St. Anne in honor of the original monastic shrine.          

Growth and expansion

With the canonization of Dimitry of Rostov in 1757, Empress Elizabeth (daughter of Peter the Great) made lavish donations, including a silver sarcophagus to hold the saint’s relics in the Conception Cathedral. This remarkable object was melted down by the Bolsheviks in 1922. 

Rostov Kremlin Museum. Portrait of St. Dimitry of Rostov by Vladimir Borovikovsky, 1790. Summer 1911

Rostov Kremlin Museum. Portrait of St. Dimitry of Rostov by Vladimir Borovikovsky, 1790. Summer 1911

The monastery’s prestige was greatly enhanced by Catherine the Great, who chose the monastery for the first pilgrimage of her reign. Her visit, in late May 1763 for the solemn transfer of Dimitry’s relics to the silver sarcophagus, proved to be an event of major symbolic importance for the new empress’s consolidation of power.          

The following year the monastery was elevated in status and supervised directly by the Holy Synod, the main governing body of the Russian Orthodox Church from 1721 to 1917. This assured it of major financial support at a time when many monasteries were being closed by Catherine’s reform of the monastic system.

St. Dimitry Cathedral, south view. July 8, 2019

St. Dimitry Cathedral, south view. July 8, 2019

In 1764 the monastery was also granted the property of the adjacent Transfiguration of the Savior Monastery, In honor of the merger, the monastery was renamed in 1765 as the Savior-St. Yakov-Conception Monastery, a designation that it retained until 1836, when it was renamed yet again to honor St. Dimitry of Rostov.          

The greatest homage to the prelate was the building in 1795-1801 of the grand neoclassical Church of St. Dimitry, Metropolitan of Rostov. This magisterial structure, usually referred to as a cathedral, was photographed by Prokudin-Gorsky on its interior as well as exterior.          

St. Dimitry Cathedral. Interior, view east toward icon screen. Summer 1911

St. Dimitry Cathedral. Interior, view east toward icon screen. Summer 1911

Support for this edifice was provided by Count Nicholas Sheremetyev (1751-1809), the grandson of Field Marshal Boris Sheremetyev (1652-1719), Peter the Great’s leading army commander. A close contemporary of Dimitry Tuptalo, Boris Sheremetyev was granted estates in the Rostov region, thus furthering his association with Metropolitan Dimitry.         

Successive generations of Sheremetyevs maintained ties with the monastery, yet none did as much as Nicholas Sheremetyev, who intended to raise a great shrine to contain the saintly prelate’s relics. Although church authorities objected to the transfer on the grounds that Dimitry had stated his desire to be buried in the Conception Cathedral, the structure of the St. Dimitry shrine was completed in 1801.          

St. Dimitry Cathedral. Interior, icon screen. July 7, 2019

St. Dimitry Cathedral. Interior, icon screen. July 7, 2019

An imposing shrine

The imposing late neoclassical exterior is attributed to the architect Elizvoy Nazarov, a former serf who did much work for the Sheremetyevs. A large central dome crowns the main block, which is adorned on the north and south facades with extended pediments resting on paired Corinthian columns. The space beneath the pediments contains stucco reliefs and statues within niches.          

Extending from the west side is a massive refectory (vestibule) framed by a portico with six Ionic columns. This extension contains secondary altars dedicated to St. Nicholas (patron saint of Nicholas Sheremetyev) and St. Demetrius of Thessaloniki, patron of St. Dimitry of Rostov.          

St. Dimitry Cathedral interior. View east toward icon screen. July 8, 2019

St. Dimitry Cathedral interior. View east toward icon screen. July 8, 2019

Although his original glass negative has not survived, Prokudin-Gorsky’s contact print shows the St. Dimitry Cathedral rising above the monastic ensemble at the north wall and the Holy Gate. My photographs show the cathedral from various perspectives within the monastery.         

Prokudin-Gorsky also photographed the monumental interior of the cathedral, decorated and renovated over a period from the beginning of the 19 th to the beginning of the 20 th century. His general interior view toward the east includes the neoclassical icon screen, recreated in 1869-70.          

St. Dimitry Cathedral interior. Baldachin with silver sarcophagus containing relics of St. Dimitry of Rostov. Summer 1911

St. Dimitry Cathedral interior. Baldachin with silver sarcophagus containing relics of St. Dimitry of Rostov. Summer 1911

A second view shows a marble baldachin that contained a second silver sarcophagus made in 1910 following the bicentennial of St. Dimitry’s death. At that point, his relics were transferred during each summer from the Conception Cathedral to the St. Dimitry shrine, which Prokudin-Gorsky photographed in 1911. This second sarcophagus was also melted down for its silver in 1922.         

St. Dimitry Cathedral interior. Baldachin with silver sarcophagus  (third) containing relics of St. Dimitry of Rostov. July 7, 2019

St. Dimitry Cathedral interior. Baldachin with silver sarcophagus (third) containing relics of St. Dimitry of Rostov. July 7, 2019

The monastery’s prosperity came to an end with the establishment of Soviet power. After its closure as a religious institution in 1923, some monastery treasures were preserved by the Rostov Museum, but the monastery in general was ransacked and then disfigured by haphazard conversion to other uses. The extent of the degradation is evident from my photographs taken in the early 1990s soon after the return of the monastery to the Orthodox Church in April 1991.         

St. Dimitry Cathedral interior. Dome with medallions depicting 12 Apostles. July 7, 2019

St. Dimitry Cathedral interior. Dome with medallions depicting 12 Apostles. July 7, 2019

In 2009, during the tercentenary of St. Dimitry’s death, the restored Cathedral of St. Dimitry was re-consecrated by Patriach Kirill. For this occasion, a third silver sarcophagus was made to contain the saint’s relics throughout the year. Ongoing restoration efforts have returned the monastery dedicated to St. Dimitry to a position as one of the most illustrious in central Russia.

In the early 20th century the Russian photographer Sergei Prokudin-Gorsky developed a complex process for color photography. Between 1903 and 1916 he traveled through the Russian Empire and took over 2,000 photographs with the new process, which involved three exposures on a glass plate. In August 1918 he left Russia with a large part of his collection of glass negatives and ultimately resettled in France. After his death in Paris in 1944, his heirs sold his collection to the Library of Congress. In the early 21st century the Library digitized the Prokudin-Gorsky Collection and made it freely available to the global public. A number of Russian websites now have versions of the collection. In 1986 the architectural historian and photographer William Brumfield organized the first exhibit of Prokudin-Gorsky photographs at the Library of Congress. Over a period of work in Russia beginning in 1970, Brumfield has photographed most of the sites visited by Prokudin-Gorsky. This series of articles will juxtapose Prokudin-Gorsky’s views of architectural monuments with photographs taken by Brumfield decades later.

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Orthodox Christianity

Holy Hierarch St. Dimitry of Rostov

Commemorated 28 october/10 november.

Holy Hierarch St. Dimitry was born in 1651 in the settlement of Makarov, within the confines of Kiev. At his Baptism, he was given the name Daniel. His father Savva, also known as Tuptalo, was a regimental centurion [i.e. lieutenant]. Daniel enrolled in a school in Kiev, and from his early youth manifested great zeal dedication to prayer and study, preferring reading books and listening to pious conversations, over playing noisy games with his companions. Over the years, this only intensified, and at the age of 17, with his father’s blessing, he entered monastic life at the St. Kirill Monastery. There, as he became ever more resolute in faith and piety, Dimitry (the name he was given at his tonsure), also assiduously continued with his studies, and learned a number of languages. Possessing God-given intellect and talents, he used the gifts given him by the Lord for good, and like the faithful servant spoken of in the Gospels, he multiplied the talent entrusted to him, using it in the service of God and for the benefit of his neighbor. He preached the Word of God in Kiev, Chernigov, and in various monasteries, was an abbot at the Maksakov and later the Baturin Monasteries. His sermons attracted a multitude of listeners, and buttressed Orthodoxy in regions where close and frequent interaction between the local populace and the neighboring Papists had caused it to waver somewhat.

Soon Dimitry was called to perform a different labor. There was a need to assemble a collection of the Lives of the Saints. Metropolitan Makary had long since begun the task of collecting the Lives of Saints from various sources and assembling them in his great volumes of the Menaion. Later, Metropolitan Peter Mogila of Kiev expressed the desire to publish them in language more accessible to all. However, he died before he could accomplish his goal. Now the Metropolitan of Kiev was looking for someone to whom he could entrust that task. He settled on Dimitry, who was already renowned for his piety, erudition, and industriousness. Dimitry began this useful work while he was abbot of the Baturin Monastery, and gradually worked on it over the course of 20 years – as Archimandrite in Chernigov and in Novgorod of the North, and then as Metropolitan of Rostov. In that Menaion, he assembled the lives of the Saints for each day of the year, a task for which we owe him a profound debt of gratitude.

Meanwhile, Peter, the reigning Emperor of Russia appointed Dimitry to be Metropolitan of Siberia and Tobolsk. However, the Hierarch’s poor state of health, as well as the task he had undertaken, prevented him from setting out on the long journey to Siberia. Accordingly, he was reassigned, to be Metropolitan of Rostov and Yaroslavl. Remembering the Savior’s statement that of one to whom much is given, much will be required, Dimitry in his new exalted rank, he worked even more assiduously to care unstintingly for those entrusted to his care. He used his own funds to build a school in Rostov, oversaw the class work, and when his complex schedule of activities permitted., often taught there himself. He tirelessly strove to explain Christ’s teaching through lectures and homilies, and set a good example by his temperate, God-fearing, and honest way of life. A person who was kind, compassionate, and accessible to all, he helped his neighbor by all means possible. He would eagerly impart advice and instruction, would visit the sick, and would be generous with gifts of food and clothing to the needy, keeping almost nothing for himself. Thus, at his death, he left nothing but his holy books.

The endless activity imposed on St. Dimitry with his new rank did not prevent him from zealously continuing the work of the Menaion; moreover, he also wrote many religious books, prayers, and liturgical hymns. His new position demanded ever greater efforts on his part. Around this time, out of sketes in Kostroma, Nizhegorod and the forests of Bryansk, schismatics began to disseminate erroneous interpretations of the Word of God, and with their false teachings brought confusion to those who were not firmly established in the Faith and in the Law of God. Dimitry presented convincing arguments in his sermons in opposition to their unjust and incorrect teaching; he also criticized them in writing, and pointed out what constituted the truth. His most remarkable composition in opposition to the schism was his “Investigation into the Bryansk faith."

On account of those spiritual labors, the Holy Church glorifies him, calling him a zealot for Orthodoxy, rooter-out of schism, the Russian star that shone forth from Kiev and shone through Novgorod of the North, came to Rostov: a man of golden oratory, a teacher who through his teachings and miracles enlightened the entire land. Death came to the Holy Hierarch at an early age. In his 58th year he fell ill and, although the illness did not appear to be serious, and did not worry anyone else, he sensed that his end was near. On the eve of his death, he called together his choir, and attentively listened as they sang his own composition, “I place my hope in God, Thou my God, Jesus, Thou art my joy.” He dismissed all but one of the chanters – who had assisted him in transcribing his compositions. For a long time, he talked to him about life, and about the responsibilities attendant to being a Christian. Then he dismissed him as well. Escorting him to the door, St. Dimitry bowed low before him, and thanked him for all of his service. The chanter said, “Holy master, [why] are you making such a profoundly deep prostration before me, the least of servants? The Metropolitan again made a prostration, and repeated, “I thank you.” Then he knelt in prayer. The chanter returned home with a sense of mournful premonition. Early in the morning, the tolling of the bell announced the passing of the Holy Hierarch who was found dead, still kneeling in prayer. This occurred in Rostov in 1709.

Years later, the Holy Hierarch’s honorable relics and his vestments were found to be incorrupt, and in 1763, at the direction of Empress Catherine, were transferred to a silver reliquary. Since that time, a multitude of faithful have come from all over Russia to Rostov in order to bow down before the relics of the great Holy Hierarch.

The Church of St. John the Baptist, Washington, DC

 St. Peter, Tsarevich of the Horde (1290)

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education bookshelf

What's on a Spy Novelist's Bookshelf?

Former intelligence analyst and current spy novelist susan ouellette rounds up some essential espionage-adjacent reads..

It may come as no surprise that my bookshelf is dominated by spy novels and non-fiction books about the CIA and the KGB. While I prefer novels, there are several non-fiction books I consider essential to understanding the world of espionage. But first, the novels:

___________________________________

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A Gentleman in Moscow (Amor Towles)

While not a spy novel, per se, A Gentleman in Moscow is an exquisitely written tale about a Russian nobleman who finds himself on the wrong side of history after the 1917 Russian Revolution. When the new communist government declares Count Alexander Rostov an unrepentant aristocrat, he is sentenced to a lifetime of house arrest. Fortunately for the Count, he is exiled to Moscow’s luxurious Metropol Hotel, not a Siberian labor camp. Ever the gentleman and the optimist, Count Rostov builds a life for himself, even as the walls—both literal and figurative—close in around him. Towles’ story subtly depicts how the tentacles of communism invade and strangle the human spirit. The Count loses almost everything—his wealth, his freedom, his loved ones—to the communists. But the one thing the Bolsheviks cannot destroy is his spirit. And it’s that spirit which propels the story to an ending that only an indomitable character like Rostov could engineer.

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Damascus Station (David McCloskey)

I’m a few chapters into Damascus Station , a debut spy thriller by David McCloskey, whose career mirrors mine in several ways. We both worked at the CIA, wrote a story that sat in a drawer for some time, worked for a consulting firm, and then finally published a novel. McCloskey’s understanding of the world of espionage comes through clearly in the opening pages of the story. From his case officer’s well—executive surveillance detection route to the briefings, debriefings, and interrogations involving American and Syrian intelligence agencies—this story brims with authenticity and tension. I look forward to reading the rest.

Books, Books, and More (Spy) Books!

Robert Littell: One of my favorite spy novelists, Littell has written dozens of intricately plotted Cold War espionage novels. Among my favorites are The Company and An Agent in Place .

Tom Clancy: When I read The Hunt for Red October , I began to wonder if I could write a story that would keep readers up reading way past their bedtimes. It lit a spark in me that took years to develop, but I finally started writing because of this book (casting Sean Connery as Captain Ramius also helped!). Other Clancy books I love include Red Storm Rising, Patriot Games, Clear and Present Danger, and The Sum of All Fears.

Nelson DeMille: I love DeMille’s John Corey series. Corey is a wise-cracking, street-smart, retired homicide detective turned anti-terrorist special agent who makes me laugh out loud. I highly recommend Plum Island, The Lion’s Game , and Night Fall . I also love many of DeMille’s other novels, especially The Charm School, The Gold Coast, and The General’s Daughter.

Daniel Silva: I have read about a dozen of Silva’s spy novels, most of which feature his Israeli intelligence hero, Gabriel Allon. Fantastic books. I remember reading one of his standalone books, The Unlikely Spy, before I had joined the CIA. A friend asked me if it was a novel or a personal how-to guide. Ha!

(There are so many authors I could add to this list, from Robert Ludlum, to Ken Follett, to Vince Flynn and more. Is there a book club for spy thriller fans? If not, perhaps there should be!)

The Spy and the Traitor

The Spy and the Traitor (Ben McIntyre)

The Spy and the Traitor is simply the best non-fiction spy story ever told. It’s a gripping, Cold War era page-turner about a senior KGB officer who spied for British intelligence. Oleg Gordievsky hailed from a family of Soviet intelligence officers, but a series of events made him question his work for and loyalty to the KGB and his country. First came the 1956 Soviet invasion of Hungary, then the building of the Berlin Wall in the early 1960s, and finally, the crushing of the Prague Spring in 1968. His disillusionment with communism and the Soviet system deepened after his time stationed in Denmark and England. Gordievsky’s role in keeping the Cold War from turning hot cannot be understated. For fans of espionage thrillers, The Spy and the Traitor is a must read (and a must listen for audiobook fans. Narrator John Lee does an exceptional job.).

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KGB, The Inside Story (Christopher Andrew and Oleg Gordievsky)

The aforementioned Oleg Gordievsky joined forces with Christopher Andrews to write a comprehensive history of the KGB. If you are interested in Cold War intelligence history, this book is mandatory reading.

education bookshelf

The Great Terror (Robert Conquest)

The Great Terror is considered the definitive work on Josef Stalin’s Great Purge on the late 1930s, during which millions of “enemies of the state” were killed or imprisoned in the USSR’s notorious gulags . The edition sitting on my bookshelf is the original book, published in 1968. Conquest updated the book in 1990 after gaining access to Soviet historical archives. The Great Terror: A Reassessment added even more detail about the horrors of Josef Stalin’s reign. (Adding it to my must-read list.)

education bookshelf

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Susan Ouellette

Previous article, next article, get the crime reads brief, get our “here’s to crime” tote.

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Saint of the Day

Saint of the Day

St dimitri (demetrius) of rostov (1709).

October 28, 2019 Length: 2:54

Born near Kiev, he was raised in piety and, at the early age of eleven, entered the Ecclesiastical Academy of Kiev. At the age of seventeen he was professed as a monk. A few years later he was ordained to the priesthood. Despite his constant desire to retire into a life of asceticism and solitude, his many gifts were needed by the Church and, much against his will, he spent most of his life engaged in writing and other labors. The Abbot of the Lavra of the Kiev Caves, knowing his scholarly abilities, called him to compile a Russian-language Lives of the Saints, a work to which he devoted himself tirelessly for twenty-five years.   This compilation was not a dry exercise for him; he approached each Saint's life with prayer, and was often granted visions. The holy Martyr Barbara appeared to him in his sleep in 1685; when he asked her to intercede for him to the Lord, she chided him for praying "in the Latin Way," that is, for using short prayers. Seeing his distress at being so rebuked, she smiled and said "Do not be afraid!"   St Demetrius was elevated to the episcopal throne (of Metropolitan of Tobolsk and Siberia) in 1701, but asked to be transferred due to ill health, and because the Siberian see would not allow him to continue his research. So he was appointed to the Diocese of Rostov in 1702; he received a divine revelation that he would end his years there. He completed his monumental Lives of the Saints in 1705; thereafter he devoted his energies to the care of his flock, the education of priests, and many spiritual writings, including several addressed to the schismatic "Old Believers," pleading with them to rejoin the canonical Church.   Despite his poor health, he maintained a life of strict prayer and fasting, and encouraged his faithful, in his sermons and writings, to do the same. He predicted his own death three days beforehand. The Synaxarion concludes: "the holy Bishop fell at the feet of his servants and chanters, and asked their forgiveness. Then, with an ardent prayer on his lips, he shut himself in his cell. The next morning, 28 October 1709, they discovered him dead upon his knees. The relics of Saint Demetrius were found incorrupt in 1752 and they wrought many healings. He was formally glorified by the Church in 1757."

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  20. Regal splendor: The Monastery Cathedral of St. Dimitry in Rostov

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  22. Holy Hierarch St. Dimitry of Rostov / OrthoChristian.Com

    Holy Hierarch St. Dimitry was born in 1651 in the settlement of Makarov, within the confines of Kiev. At his Baptism, he was given the name Daniel. His father Savva, also known as Tuptalo, was a regimental centurion [i.e. lieutenant]. Daniel enrolled in a school in Kiev, and from his early youth manifested great zeal dedication to prayer and ...

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  24. What's on a Spy Novelist's Bookshelf? ‹ CrimeReads

    The edition sitting on my bookshelf is the original book, published in 1968. Conquest updated the book in 1990 after gaining access to Soviet historical archives. The Great Terror: A Reassessment added even more detail about the horrors of Josef Stalin's reign. (Adding it to my must-read list.) ***

  25. St Dimitri (Demetrius) of Rostov (1709)

    St Dimitri (Demetrius) of Rostov (1709) Born near Kiev, he was raised in piety and, at the early age of eleven, entered the Ecclesiastical Academy of Kiev. At the age of seventeen he was professed as a monk. A few years later he was ordained to the priesthood. Despite his constant desire to retire into a life of asceticism and solitude, his ...