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Inclusive & Bias-Free Curriculum Checklist

This checklist is adapted, with permission, from the Checklist for Assessing Bias in Medical Education Content developed by Dr. Amy Caruso Brown at SUNY Upstate Medical University. Her webinar on this very important topic can be viewed  De-Biasing Medical Education: A Checklist Methodology.

How to Use this Checklist

When creating or reviewing educational content for Feinberg students and trainees, the following questions are meant to create pause and encourage critical reflection on how race, gender, and other socioeconomic factors are represented in your educational content.  Please consider whether one or more social indicators (race, gender, age, etc.) are discussed in your content (this includes photos). Follow the prompts to expand the area that will provide recommended and/or preferred ideas for content delivery.

This checklist should be used to evaluate the content of a variety of teaching modalities 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: We all recognize patterns of bias that a single lecturer or facilitator may not appreciate. You are not alone in reviewing your content and there are always resources available. Additionally, please use the available bias disclosure slide indicating your use of this checklist.  The disclosure slide signals to the viewers of your content the importance of and commitment to mitigating bias in the Feinberg learning environment.

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 and maintain an inclusive environment, we strive to avoid burdening or marginalizing our students and educators who may personally face the lasting impact of these indicators.  As members of this community, we must all do our part to be allies to create an environment of belonging.

Need Help?

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

Race or Ethnicity (if photos are present, race IS included)

 Does the content mention race or ethnicity? If photos are present, race is included in the educational content.

If yes or unsure, expand.

Race: Grouping of humans based on shared physical or social qualities into categories generally viewed as distinct by a society; importantly, race is a social, not a biological construction, and a person’s racial grouping will vary between countries and societies

Ethnicity: Groups (e.g., Fijian, or Sioux, etc.) that share a common identity-based ancestry, language, or culture; often based on religion, beliefs, and customs as well as memories of migration or colonization (Cornell & Hartmann)

 

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

 Are explicit biological differences between racial or ethnic groups stated?

If yes or unsure, expand.

  • 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.

 Are biological differences between racial and ethnic groups implied?

If yes or unsure, expand.

  • 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.

 Could this content be perceived as promoting racial/ethnic stereotypes, bias, shame or stigma?
If yes or unsure, expand.

  • 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
It is strongly encouraged to change the content.  If additional assistance with content is required, please feel free to contact the taskforce.

 Additional Resources

Visual Images

  Was consent obtained for use of these images?

If no or unsure, expand.

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.

 Does the image add relevant/important content to the lecture?

If no or unsure, expand.

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

 Could the image(s) promote stereotypes and/biases?

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 (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).

 Does the image(s) promote racial and ethnic diversity?

If no or unsure, expand.

Consider adding additional content that promotes racial and ethnic diversity.

 If using images of physical findings, are they representative of diverse patient populations including varying skin tones or other physical features that may be impacted by unique patient attributes?

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.

 Are people depicted in the images diverse in terms of body habitus (e.g.; shape, size, physical disability)?

If no, expand.

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

 If using image(s) to illustrate morphological features of disability, are the image(s) primarily tragic or negative (e.g., suggesting a poor quality of life)?
If yes or unsure, expand

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

 Relevant References:

 Jackson-Richards D, Pandya AG, editors. Dermatology atlas for skin of color. Springer; 2014 Jul 19.

Moiin A, editor. Atlas of Black Skin. Springer Nature; 2020 Jan 24.

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

 Is gender diversity represented in the content?

If no or unsure, expand?

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)

 Is gender presented using a non-binary framework?

If no or unsure, expand.

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.

 Does the content conflate gender identity with sexual orientation?

If no or unsure, expand.

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.

 Does the content rely heavily on bias toward traditional gender roles? (i.e. nurses are women, doctors are men).

If yes or unsure, 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/they pronouns.

 Are symptoms, signs, other clinical findings and/or disease presentations (e.g., chest pain) referred to as "atypical" or "variant" when they occur in women?

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

 Could the content be perceived as promoting stereotypes, bias, shame or stigma of LGBTQ+ community?
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, 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, Sexual Behavior and Sexual Orientation

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

If yes or unsure, expand.

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) 

 Is the spectrum of sexual orientation represented in the content?

If no or unsure, expand.

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.

 Does the content promote shame, bias, stereotype or stigma related to 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"
  • 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 the content may promote shame, bias, stereotypes or stigma, the content should be removed.  If further assistance is needed, please contact the task force.

 Does the content recognize the sexual health needs of older patients, including geriatric patients?
If no or unsure, expand

It is important to recognize the spectrum of sexuality and sexual health.  If relevant to the material, please consider adding this content. If you need further assistance, please contact the task force.

 Does the content recognize the sexual health needs of patients with physical disabilities?
If no or unsure, expand.

It is important to recognize the spectrum of sexuality and sexual health.  If relevant to the material, please consider adding this content. If you need further assistance, please contact the task force.

 Additional Resource:
Rowen TS, Stein S, and Tepper M. Sexual health care for people with physical disabilities. J Sex Med 2015;12:584-589.

Disability

 Does the content include any mention of disability (visible or invisible)?
If yes or unsure, expand.

Disability: "Impairments, activity limitations, and participation restrictions; an impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations; complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives" (WHO)

 Does the content promote shame, bias, or stereotypes from a disability standpoint?
If yes or unsure, expand.

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.

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 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. 

Additional Resources:
Jain NR. Political disclosure: resisting ableism in medical education. Disability & Society. 2020 Mar 15;35(3):389-412.

Santoro JD, Yedla M, Lazzareschi DV, Whitgob EE. Disability in US medical education: Disparities, programmes and future directions. Health Education Journal. 2017 Oct;76(6):753-9.

 Seidel E, Crowe S. The state of disability awareness in American medical schools. American journal of physical medicine & rehabilitation. 2017 Sep 1;96(9):673-6.

 Does the content include positive representations of disability (e.g., as typical human variation or diversity)?
If no or unsure, expand.

If your material does not include any positive content, the task force advises that you consider adding positive representations. If you need additional assistance, please contact the task force.

Mental Health and Substance Use

 Does the content promote shame, bias, or stereotypes from a mental health or substance use standpoint?

If yes, unsure or to see examples, expand.

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. 

Weight

 Does the content assume a straightforward relationship between weight (or body mass index) and health?

If yes or unsure, expand.

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.

 Does the content solely emphasize personal responsibility in discussions of obesity?
If yes or unsure, expand.

If your material includes any such content, the task force advises that you consider editing the content to address the complexity of obesity with social determinants of health, mental health and toxic stress.  If you need additional assistance with this content, please contact the task force.

 Does the content discuss genetic, epigenetic, social and structural risk factors related to obesity?
If no or unsure, expand

The task force advises that the content should be edited to address the complexity of obesity with social determinants of health, mental health and toxic stress.  If you need additional assistance with this content, please contact the task force.

 Could the content be perceived as promoting stereotypes, bias, shame or stigma?
If yes, unsure, expand.

Here are some examples of statements that may promote stereotypes, bias, shame and stigma:
  • 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
If your educational material includes any such content, the task force advises that you consider changing or removing that content.

 Additional resources:

Brown H. Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight—and What We Can Do about It. Philadelphia, PA: Da Capo Press, 2015.

Daniel C. Economic constraints on taste formation and the true cost of healthy eating. Social Science & Medicine. 2016 Jan 1;148:34-41.

Guthman J. Weighing In: Obesity, Food Justice, and the Limits of Capitalism. University of California Press, 2011.

Knowles M, Rabinowich J, De Cuba SE, Cutts DB, Chilton M. “Do you wanna breathe or eat?”: parent perspectives on child health consequences of food insecurity, trade-offs, and toxic stress. Maternal and child health journal. 2016 Jan 1;20(1):25-32.

Immigration Status, Nationality, Language and Culture

 Does the content include any mention of immigration status, nationality, language or culture?

If yes or unsure, expand.

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

 Does this content distinguish between different categories of immigration status, including refugees, asylum seekers, and undocumented immigrants, "green card holders", etc.?
If yes or unsure, expand.

If your material includes any such content, the task force strongly advises that you discuss the content in a respectful and non-stereotypical manner absent of any personal political opinions.  If you need further assistance, please contact the task force.

 Could this content be understood as suggesting that patients who do not speak English are less capable of understanding healthcare information, making informed healthcare decisions or adhering to healthcare recommendations?
If yes or unsure, expand.

If your material includes any such content, the task force advises that you discuss the content in a respectful and non-stereotypical manner void of any political influence.  If you need further assistance, please contact the task force.

 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:
  • 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
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 or unsure, expand.

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.

Age

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

If yes, unsure, 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
  • 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
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.

Incarceration

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

If yes or unsure, expand.

If this is mentioned and relevant to the material the task force recommends discussing the special healthcare needs of the prison population. If you need further assistanceassistance, please contact the task force.

 Does the content discuss mass incarceration as a public health problem (e.g., the school-to-prison pipeline)?
If no or unsure, expand.

If this is mentioned and relevant to the material the task force recommends discussing the complexity of mass incarceration including societal structures that likely contribute to the public health problem. If you need further assistance, please contact the task force.

 If this is mentioned and relevant to the material the task force recommends discussing the complexity of mass incarceration including societal structures that likely contribute to the public health problem. If you need further assistanceassistance, please contact the task force. 
If yes or unsure, 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 materials include 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.