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Inclusive & Bias-Free Curriculum Checklist

This checklist is adapted from the Checklist for Assessing Bias in Medical Education Content developed by Dr. Amy Caruso Brown at SUNY Upstate Medical University. We use it with Dr. Caruso Brown's permission. You can also view her webinar De-Biasing Medical Education: A Checklist Methodology.

How to Use It

When creating or reviewing educational content for Feinberg students and trainees, the following questions can encourage reflection on how race, gender, and other socioeconomic factors are represented your content. Please consider whether one or more indicators (race, gender, age, etc.) is discussed in your educational content (this should include photos). If your answer is "yes" to any of the questions below, expand the area to evaluate recommended/preferred delivery of this content.

This checklist can be used to evaluate a variety of teaching content including (but not limited to) lecture slides, learning guides, clinical vignettes, multiple-choice questions, case-based learning materials and standardized patient encounter scripts.

Please note: These examples require some awareness of content across sessions, units and courses. Remember that learners can recognize patterns of bias that a single lecturer or facilitator may not appreciate. When reviewing the details of a case study or vignette, we recommend thinking about how it would affect learners if every patient with that condition was presented as being a particular race, ethnicity, sexual orientation, etc.

Why It's Important

The factors addressed below are often associated with marginalization and inequality in healthcare, access to care and health outcomes. Additionally, in our efforts to create an inclusive environment, we strive to avoid burdening or marginalizing our students and educators who may personally face the lasting impact of these indicators.

Moving Forward

The Task Force on Inclusion & Bias is available to help faculty analyze and improve on their content. For information, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

Race or Ethnicity

 Does the content include any mention of race or ethnicity?

For examples, expand.

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

  • Teaching the practice of race “correction” for highly variable physiological measures such as spirometry values and glomerular filtration rate, based on outdated studies, neglecting intrinsic variation within racial groups
  • Presenting associations between race and disease incidence without context
  • 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 diabetes or obesity
  • Assuming Latinx patients are 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”)
  • Any comment about race or ethnicity that is meant to elicit laughter

 Are explicit biological differences between racial or ethnic groups stated?

If yes or unsure, expand.

Here are some suggestions to consider regarding the stated biological differences

  • Consider whether this is essential information
  • Verify that this is scientifically accurate, based on the most current research and that you are presenting the science behind the differences
  • If social/structural determinants of health also contribute to the difference, say so
  • Assure that students understand racial groups are not biological constructs
  • If the rationale for inclusion is that it is a cue for the correct answer on multiple-choice tests, make that clear (Note: evidence suggests that excessive reliance on quick associations between patient characteristics and diseases leads to misdiagnosis)

 Are biological differences between racial or ethnic groups implied?

If yes or unsure, expand.

Here are some suggestions to consider regarding the implied biological differences:

  • Consider whether this is essential information; if so, state it explicitly
  • Provide context so that students understand the role of social/structural determinants of health in contributing to differences

Visual Images

  Was consent obtained for use of these images?

If no, expand.

If consent was not given to use the image, we recommend changing the content.

 Does the image add something important to the lecture?

If no, expand.

If the image does not add something important, we recommend removing the image to minimize the possibility of bias.

 Could the image suggest stereotypes or promote bias?

If yes or unsure, expand.

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, 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 and the latter are ineffective).

 Were the people depicted in the images racially and ethnically diverse?

If no, expand.

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

 If using images of physical findings, do they represent the full spectrum of skin tones or other physical features?

If no or unsure, expand.

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.

Clinical Vignettes

 Does the content include one or more clinical vignettes or other anecdotes about patients or healthcare providers?

If yes, expand.

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 and Gender

 Are all sexes, genders, and/or sexual orientations appropriately represented in the content?

If no or unsure, expand?

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

 If biological sex is presented in a binary fashion, is this appropriate?

If no or unsure, expand.

The Task Force on Inclusion & Bias is available to help you discern whether it is appropriate in the given context to present biological sex in a binary fashion. For assistance, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

 Is gender presented as part of a spectrum, rather than a binary concept?

If no or unsure, expand.

The Task Force on Inclusion & Bias is available to help you discern whether gender is presented as part of a spectrum in your content. For assistance, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

 If healthcare professionals are mentioned (e.g., in the context of a vignette), is the physician always a “he”? Is the nurse, social worker, etc. always a “she”?

If yes, expand.

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.

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes or unsure, expand.

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

Sexuality, Sexual Behavior and Sexual Orientation

 Does the content include any mention of sexual behavior, sexuality or sexual orientation?

If yes or unsure, expand.

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

  • 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"
  • Using value-laden terms like "prostitute" instead of the more neutral "sex worker"
  • Any comment about this subject that is meant to elicit laughter

 Is the spectrum of sexual orientation represented in the content?

If no or unsure, expand.

It is important to represent the full spectrum of spectrum of sexual orientation. The Task Force on Inclusion & Bias is available to help you discern whether all sexes, genders, and/or orientations are appropriately represented in the given context. For assistance, contact Khalilah Gates, MD, task force leader, via email at k-gates@northwestern.edu.

Disability

 Does the content include any mention of disability?

If yes or to see examples, expand.

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

If your training 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.

Mental Illness and Substance Use

 Does the content include any mention of mental illness or substance use?

If yes, unsure or to see examples, expand.

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

  • Implying that mentally ill patients are violent/dangerous
  • 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 "addicts"
  • Any 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.

Weight

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes, unsure or to see examples, expand.

Avoid including content that assumes or implies a linear or straightforward relationship between weight and health.

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

  • Vignettes that describe overweight and obese patients as “noncompliant”
  • Emphasizing personal responsibility in discussions of obesity at the expense of important genetic/epigenetic, social and structural risk factors
  • Assuming that all overweight and obese are unhealthy, when it is much more complicated biologically
  • Any 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.

Immigration Status

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes, unsure or to see examples, expand.

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

  • 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 or implying that certain populations are undocumented immigrants/migrant workers
  • Any comment about any of the above 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.

Poverty

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes, unsure or to see examples, expand.

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.
  • 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.

Age

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes, unsure or to see examples, expand.

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

  • Focusing only on declining health/quality of life and need for advance directives/limitations of care; ignoring positive portrayals of aging and geriatric care
  • Neglecting consideration of sexual health at all ages
  • Any comment about weight 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.

Religion

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?

If yes, unsure or to see an example, expand.

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.

 Does that content assume that religious groups are monolithic and present their beliefs as such?

If yes, unsure or to see an example, expand.

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.

Prisoners

 Does the content include any discussion of incarceration or of the special healthcare needs of prisoners?

If yes, unsure or to see an example, expand.

Examples of content that promotes shame, bias, stereotype or stigma include:
  • Implying that prisoners are less deserving of healthcare than others
  • Assuming the guilt of all those charged with crimes or incarcerated

If your training includes any such content that could be perceived as promoting stereotypes, bias, shame or stigma, the task force advises that you consider changing or removing that content.

Interprofessional Communication

 Does this content discuss healthcare practitioners from more than one profession (e.g., medicine, nursing, physical therapy) or specialty (e.g, pediatrics, emergency medicine)?

If yes, unsure or to see an example, expand.

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.