Guidelines for Promoting a Bias-Free Curriculum

Inclusion is one of the school-wide values of Columbia University Vagelos College of Physicians and Surgeons (P&S). These guidelines should be viewed as a resource for educators to increase inclusion and reduce bias in the medical school curriculum. These guidelines, informed by feedback from many P&S students and faculty, identify 6 areas for consideration when developing curricular material and teaching students.

  1. Be inclusive in representations of healthy/normal.
  2. Be inclusive in representations of pathology.
  3. Avoid stereotypes in representations of pathology.
  4. Acknowledge limitations of research.
  5. Explore differences in health outcomes and responses to treatment.
  6. Consider informal attitudes and behavior.

1. Be inclusive in representations of healthy/normal.

Example: A textbook may describe healthy gums as being “coral pink” in color; yet, healthy gums of persons of color may be pigmented. Such a limited description of normal may not be preparing students to work with a diverse patient population and risk inadvertently communicating to some students that they are not “normal”.

Solution: When describing human structure, function, or behavior, consider whether a representation applies universally or whether more broad descriptions are needed. An educator teaching the material above may present images of gums of different normal pigmentations. In addition, teachers can strive to craft cases for class discussion, simulation, or examination that are inclusive with regard to race, religion, sex and gender, and other domains of identity.

2. Be inclusive in representations of pathology.

Example: Hyperbilirubinemia can present clinically as jaundiced skin. However, in darker-skinned persons, jaundiced skin may be clinically difficult to appreciate.

Solution: An educator may first consider whether the clinical presentation of a disease may vary across populations and discuss those differences with students. In the example above, the educator can discuss the challenges of identifying skin color changes in persons with darker skin and might discuss how one can look at palms and sclera for clinical clues in these patients. Alternatively, in a case where the descriptors used for pathology are consistent across groups, such as peau d’orange to refer to the dimpled appearance of cutaneous lymphatic edema, the educator could be explicit about the universality of the trait.

3. Avoid stereotypes in representations of pathology.

Example: A discussion on sexually transmitted infections (STIs) may use “typical” case examples to illustrate disease pathology and epidemiology (e.g. men who have sex with men or young people). We may be inadvertently teaching students to think that these are the only kinds of persons who are at risk for STIs. Similarly, we risk suggesting that all or most individuals in a particular group have STIs. This type of stereotypical representation is particularly problematic for conditions associated with social stigma.

Solution: Consider using a diverse set of case examples that illustrate both the typical populations at risk for certain diseases (guided by evidence-based knowledge of population prevalence) while avoiding the impression that only those populations are at risk. For instance, a teacher may discuss a geriatric or pediatric patient who develops an STI or a case that focuses on the sexual health of a woman who has sex with women. Another example of teaching that disrupts stereotypes and biases in clinical thinking might be to craft a case of a man who has sex with men who presents with a fever and turns out not to have HIV or an STI but rather has a common infectious process that any immunocompetent person might develop.

4. Acknowledge limitations of research.

Example: It is common to encounter studies in the medical literature that disproportionately enroll men or people of Caucasian descent. In certain situations we may find that the generalizability of those findings to women, persons of color, or other underrepresented populations may be limited or problematic.

Solution: Educators who are sharing evidence from the literature should be aware of the limitations of that evidence, including the selection methods for the population under study. If underrepresentation in study subjects by gender identity, sex, race, socioeconomic status or another meaningful variable may limit its generalizability to other populations, this should be disclosed and serve as a point of conversation with the students. Critically examining published evidence in this way encourages a more sophisticated appraisal of the literature. This practice also consciously considers the challenges in applying research findings to diverse populations and promotes a mindfulness of diversity itself. Dialogue could be encouraged even when study subjects across groups appear represented, because the categories are often poorly defined and might not be as generalizable as the study suggests (e.g., using a sample of a Yoruba population in Nigeria to compare “Africans” or “blacks” to Caucasian Americans).

5. Explore differences in health outcomes and responses to treatment.

Example: The medical literature now describes many examples of health care disparities by race, socio-economic status, and other variables. However, the mediators of those disparities are not always known and even if known, are not always discussed. This may leave some students with a misguided impression that genetic or intrinsic differences drive all such disparities.

Solution: Though the factors that mediate the health care disparities are often not fully elucidated, it can be worthwhile for educators to foster a discussion surrounding what may be driving disparities. Such conversations will help some students move from a misguided notion that genetic differences drive all such health care disparities to developing a more nuanced understanding of how race, socio-economic status, unconscious bias, and other factors impact health care. Furthermore, students may develop an increased understanding of structural inequalities that may be driving many of the disparities seen.

6. Consider informal attitudes and behaviors.

Example: Humor is often a useful tool when teaching. However, while some may find a particular joke to be a useful mnemonic device or an engaging part of the teaching experience, others might be offended or feel excluded. The teacher risks alienating the learner or distracting the learner from the teaching point, particularly if the joke comes at the expense of a particular identity group (see below for a partial list of domains of identity).

Solution: Educational research indicates that informal attitudes and behavior in the educational setting powerfully affect the student experience. For instance, while educators are encouraged to use humor in their teaching, they should remain cognizant of whether a particular group is being targeted as a result of the joke, or whether the joke is directed to certain audience members, excluding others. In this case, the joke should either be modified, or avoided altogether.

Examples of Domains of Identity to Consider

  • Race & ethnicity
  • Sex
  • Gender Identity
  • Sexuality
  • Ability (mental, emotional, and physical)
  • Socioeconomics
  • Age
  • National origin and geography
  • Culture and behavior
  • Political and religious views