Inclusive & Bias-Free Curriculum Checklist

If your content discusses race or ethnicity, please review all material in this section.

• Does this content use race as a biological construct?  It is recommended that you remove race from the content or use it is a sociological construct.
• If there are genetic components to the content, we recommend use of “ancestry” instead of “race”. 
• If you still decide to use race/ethnicity in the content (if you answer “no” to any of these, consider omitting the content):
  • Is this information essential to the learning objectives? 
  • Is this information scientifically accurate?
  • Is this information based on the most current research? 
  • Do you present the scientific data behind the differences discussed in the content?
• Additionally, if race is to be used in the content it is recommended that you: 
  • Describe how social/structural determinants of health also contribute to the difference(s) instead of being attributed to race alone.
  • Discuss the role of toxic stress in contributing to biological differences between socially constructed races where appropriate.
  • If the rationale for inclusion of race/ethnicity is that it is a cue for the correct answer on multiple-choice tests, make that clear-explicitly state that. (Note: evidence suggests that excessive reliance on quick associations (and biases) between patient characteristics and diseases leads to misdiagnosis).

If you are still unsure or have questions about this content, please contact the taskforce for assistance.

• Consider whether this is essential information. If so:
  • Explicitly state and provide context so that learners understand the role of social/structural determinants of health in contributing to the differences attributed to race.
• If not essential, remove content.

If you are still unsure or have questions about this content, please contact the taskforce for assistance.

• Examples of the use of race/ethnicity that promote medical bias, shame, stigma and/or stereotypes:
  • Use of race “correction” for highly variable physiological measures such as spirometry values and glomerular filtration rate (GFR), based on outdated studies, neglecting intrinsic variation within racial groups
  • Presenting associations between race and disease incidence without context of social determinants of health
  • Showing two photos side-by-side during an obesity lecture: one depicting a family comprised of thin white individuals sitting down to a healthy dinner and one depicting a family of overweight black individuals sitting in front of fast food
  • Consistently showing images of black individuals when addressing asthma, diabetes or obesity etc.
  • Using only Latinx patients when discussing undocumented immigrants / migrant workers
  • Stating or implying that all patients from a particular culture participate in certain practices or reject certain medical interventions (e.g., “Muslim women are not permitted to be examined by male physicians”)
  • Use of cultural/ethnic terms to describe things not associated with a particular race/culture (i.e. bacteria that looks like "Chinese lettering"
  • Any content meant to elicit laughter

If consent was not given to use the image(s), we recommend selecting a different image(s) and/or reconsidering the need for use of images.

If the image does not add something important, we recommend removing the image to minimize the potential for bias

If the image could suggest stereotypes or promote bias, we recommend removing the image to reduce the impact of those stereotypes and bias on the students.

Be particularly cautious with cartoons and other images that are meant to be comical (which is ineffective), as well as with images that are de-identified in some way (headless, eyes covered with black bars-these may imply that the person photographed should be ashamed of being identified).

Consider adding additional content that promotes racial and ethnic diversity.

If multiple images or images of physical findings will be used, it is important that the images be more representative of the full spectrum of racial and ethnic groups be used.

Consider adding more diverse body types or completely omitting images if they do not enhance the content being presented.

Consider adding images that reflect more positive attributes in patients with these disabilities.

If the patients and healthcare providers are identified by race or ethnicity, sex or gender sexual orientation, educational background or socioeconomic status, identifiable disability or age, consider if these indicators are relevant to the vignette.

The Task Force on Inclusion & Bias is available to help you discern whether all indicators are appropriately represented in the given context. For assistance, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

Sex: “The male, female, or intersex division of a species, especially as differentiated with reference to the reproductive functions”, including “the sum of the structural and functional differences by which male, female, and intersex organisms are distinguished, or the phenomena or behavior dependent on these differences” (Thesaurus.com)

Gender: Range of characteristics pertaining to, and differentiating between, femininity and masculinity; depending on the context, these characteristics may include biological sex, sex-based social structures (i.e., gender roles), or gender identity.

Gender identity: A socially and personally constructed identity that can be associated with masculinity, femininity, androgyny, any combination of these, or altogether different conceptions of gender.

It is recommended that all genders are equitably represented in the content.  The Task Force on Inclusion & Bias is available to help you discern whether all sexes and genders are appropriately represented in the given context if needed. For assistance, contact the Task Force on Inclusion and Bias.

Here are some examples of statements that may promote stereotypes, bias, shame and stigma or inequity:

• Disproportionate course content/contact hours devoted to conditions that impact men more than women (e.g., time spent in pharmacology on drugs for erectile dysfunction vs. time spent on contraceptives)

The use of they/them pronouns is an adequate way of presenting in a non-binary framework. Course content should include the use of she/her/hers, he/him/his, and they/them/theirs equitable representing the diversity of gender identity. For assistance, contact the Task Force on Inclusion and Bias.

Sexual orientation: An inherent or immutable enduring emotional, romantic or sexual attraction to other people. Note: an individual’s sexual orientation is independent of their gender identity. (Human Rights Campaign)

Gender identity: A socially and personally constructed internal concept of one’s gender.

One should not make assumptions about a person’s sexual orientation based on their gender identity, or vice versa.

The Task Force on Inclusion & Bias is available to help you distinguish the difference between gender identity and sexual orientation. For assistance, contact the Task Force on Inclusion and Bias.

The Task Force on Inclusion & Bias would recommend that you use gender-neutral language (e.g. "the physician", "the nurse", etc.) or to alternate using he/she/they pronouns.

Here are some examples of statements that may promote stereotypes, bias, shame and stigma:

• Pediatric vignettes in which patients are invariably accompanied by a mother (never a father, two fathers, two mothers, grandparents, etc.) or only involve nuclear families with heterosexual, married parents and biological offspring
• Including maternal age as a risk factor for diseases/conditions while failing to list other risk factors that are epidemiologically more important
• Disproportionate course content/contact hours devoted to conditions that impact men more than women (e.g., time spent in pharmacology on drugs for erectile dysfunction vs. time spent on contraceptives)
• Teaching students that intersex patients are really male or female, once diagnosed properly
• Failure to use preferred pronouns for gender-nonconforming patients in clinical vignettes
• Conflating gender identity with sexual orientation
• Using language in clinical vignettes or discussions of history-taking such as “The patient admitted to having sex.”
• Teaching students to take a sexual history that does not account for the full spectrum of sexual identities and encourages categorization
• Teaching students to label sexual identities and behaviors as “high-risk”
• Any comment about biological sex, gender, or sexual orientation that is meant to elicit laughter

• Pediatric vignettes in which patients are invariably accompanied by a mother (never a father, two fathers, two mothers, grandparents, other guardians, etc.) or only involve nuclear families with heterosexual, married parents and biological offspring
• Teaching students that intersex patients are really male or female, once diagnosed properly
• Failure to use correct pronouns for gender-nonconforming patients in clinical vignettes
• Teaching students to take a sexual history that does not account for the full spectrum of sexual identities and encourages categorization
• Teaching students to label sexual identities and behaviors as “high-risk”
• Any comment about biological sex, gender, or sexual orientation that is meant to elicit laughter

Sexuality: Capacity for sexual feelings 
 
Sexual behavior: Manner in which humans experience and express their sexuality 
 
Sexual orientation:  An inherent or immutable enduring emotional, romantic or sexual attraction to other people. Note: an individual’s sexual orientation is independent of their gender identity. (Human Rights Campaign) 

It is important to represent sexual and gender minorities. The Task Force on Inclusion & Bias is available to help you discern whether sexual and gender diversity are appropriately represented in the given context. For assistance, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

• Using language in clinical vignettes or discussions of history-taking such as "The patient ADMITTED to having sex."
• Teaching students to take a sexual history that does not account for the full spectrum of sexual identities and encourages categorization.
• Teaching students to label sexual identities and behaviors as "high-risk"
• Teaching students that sexual health screening is only necessary for people with certain sexual identities
• Using value-laden terms like "prostitute" instead of the more neutral "sex worker"
• Any comment about this subject that is meant to elicit laughter.

If your material includes any such content, the task force advises that you consider changing or removing that content.  Although we recognize that there are differences of opinion within different communities and the field of disability rights, we recommend that educators without personal experience and/or expertise use person-first language. If you need additional assistance, please contact the task force.

• Failing to recognize that most people with disabilities regard their quality of life as comparable to those without disabilities.
• Assuming that people with disabilities' quality of life is not comparable to those without disabilities
• Assuming that preventive health is not as important to patients with disabilities
• Any comment about this subject that is meant to elicit laughter

Examples of content that promotes shame, bias, stereotype or stigma include:

• Implying that patients with mental illness are violent/dangerous
• Implying that patients with mental illness are not competent or capable
• Undermining the dignity of people with mental health issues by not recognizing how some might value "neurodiversity" as well as wishing treatment for symptoms that cause suffering
• Using language of personal responsibility / self-control to discuss addiction, rather than treating it as a disease
• Referring to patients as “crazy”, “insane”, "addicts", “junkies”, “drunks”
• Any comment about this subject that is meant to elicit laughter

The Task Force on Inclusion & Bias would recommend using non-stigmatizing descriptors.  If you need further assistance, please contact the task force. 

The task force advises that you consider editing the content to address the complexity of the relationship between weight and health, which are not synonymous.  If you need additional assistance with this content, please contact the task force.

• Vignettes that describe patients who are overweight or obese as “noncompliant”
• Emphasizing personal responsibility in discussions of obesity at the expense of important genetic/epigenetic, social and structural risk factors
• Assuming that all patients who are overweight or obese are unhealthy, when it is much more complicated biologically
• Any comment about this subject that is meant to elicit laughter

Immigration status: Refers to the way in which a person is present in a country; everyone has an immigration status; examples in the U.S. include citizens (by birth or naturalization), legal permanent or conditional residents, non-immigrants (present on temporary visas, such as student visas) and undocumented immigrants

Nationality: Status of belonging to a particular nation whether by birth or naturalization

Culture: Values, beliefs, systems of language, communication, and practices that a group of people and that can be used to define them as a collective; also includes the material objects that are common to the group or society (https://www.thoughtco.com/culture-definition-4135409)

• Focusing only on language barriers in clinical encounters between physicians and patients who are immigrants (assumes immigrants never speak English and neglects other important features)
• Assuming that patients who do not speak English have low-health literacy
• Assuming or implying that certain populations are undocumented immigrants/migrant workers
• Any comment about any of the above that is meant to elicit laughter

Poverty: State or condition in which a person or community lacks the resources to meet basic and essential needs for a minimum standard of living; below an income threshold set by the federal government in the U.S.

Socioeconomic status: “Social standing or class of an individual or group”; “often measured as a combination of education, income and occupation” (APA, 2021)

Here are some examples of statements that may promote stereotypes, bias, shame and stigma:

• Presenting race as a risk factor for disease occurrence or outcome without explaining role of poverty, access to healthcare, etc. (social determinants of health).
• Presenting poor people as lazy or lacking in character
• Any comment about poverty that is meant to elicit laughter

If your training includes any such content, the task force advises that you consider changing or removing that content.

• Focusing only on declining health/quality of life and need for advance directives/limitations of care
• Ignoring positive portrayals of aging and geriatric care
• Presuming that older adults are disabled and/or identify as disabled; some older adults will view disability as stigmatizing and will not identify as a person with a disability
• Neglecting consideration of sexual health at all ages
• Any comment about age that is meant to elicit laughter

Examples of content that promotes shame, bias, stereotype or stigma include:

• Mocking particular religious beliefs, especially those that are considered "outside" of the mainstream
• Presenting all deeply religious patients as rejecting mainstream medicine
• Treating religious objections to certain types of medical intervention as more worthy of consideration than other personal beliefs
• Any other comment about this subject that is meant to elicit laughter

If your training includes any such content, the task force advises that you consider changing or removing that content.

Example include suggesting that:

• All Muslim women refuse to see male providers
• All Amish families want to consult their community elders prior to making a major medical decision
• Catholic patients never use contraception

Please use caution in this area and avoid treating religious groups as monolithic; most patients interpret their religious faith or lack thereof in ways unique to them and their families.

If your training includes any such content, the task force advises that you consider changing or removing that content.

• Implying that prisoners are less deserving of healthcare than others
• Assuming the guilt of all those charged with crimes or incarcerated

Examples of content that promotes stereotypes include:

• Jokes about emergency physicians only being interested in admitting or discharging patients or orthopedic surgeons lacking basic medical knowledge outside the operating room
• Using masculine pronouns for physicians and feminine pronouns for nurses
• Implying that nurse practitioners and physician assistants are less competent than physicians

If your training includes any such content, the task force advises that you consider changing or removing that content.