Guidelines for Promoting an Anti-Bias and Inclusive Curriculum
Inclusion is a value of Columbia University Vagelos College of Physicians and Surgeons (VP&S). These guidelines for educators are intended to combat systemic racism and bias which decrease our ability to provide equitable medical care, and to increase inclusion within our medical school. Through these guidelines, co-created by VP&S students, faculty, and administrators, we aim to foster dialogue and encourage community learning around issues of bias in medicine. To learn more about this initiative, please see our main page. Students can offer feedback on any learning experience on our feedback portal.
The social construction of race
A key principle that informs our approach to promoting an anti-bias, anti-racist, and inclusive curriculum is that race is a social construct (in contrast to biologic phenomena such as skin pigmentation). Racial categories (i.e., “black” or “white”) reflect social conventions rather than meaningful biological distinctions. It is important to understand and convey race as a social construct to avoid perpetuating the false notion that differences in health outcomes along racial lines are due to biological differences between races. For more information on the social construction of both race and gender, see below for Addendum A.
With this context in mind, these guidelines identify 6 areas for consideration when developing curricular materials and teaching students:
- Be mindful of language, attitudes, and behaviors.
- Be inclusive in representations of healthy/“normal.”
- Be inclusive in representations of pathology.
- Avoid stereotypes in representations of pathology.
- Explore structural reasons for differences in health outcomes.
- Acknowledge limitations of research.
1. Be mindful of language, attitudes, and behavior.
Example: Informal language is often a useful tool when teaching. However, educators risk alienating the learner or distracting the learner from the teaching point, particularly if in reference to a particular identity group (see below for a partial list of domains of identity).
Solution: Educational research indicates that informal language, attitudes, and behavior in the educational setting powerfully affect student experiences. Educators should strive to use precise, accurate language. Examples:
- Eliminating the use of outdated and imprecise terms, e.g., “Oriental” to describe an Asian person or “Caucasian” to describe a white person.
- Using person-first language, e.g., “a person with diabetes” instead of “a diabetic” or “a person with schizophrenia” instead of “a schizophrenic.”
- Using precise gender-related language, e.g., “people with uteruses” instead of “women” if the relevant point is about the presence of a uterus rather than the person’s expressed gender identity
- Avoiding stereotypes in examples (e.g. consistently referring to nurses as "she").
2. Be inclusive in representations of healthy/“normal.”
Example: A textbook may describe healthy gums as being “coral pink” in color, when in fact healthy gums of persons of color may be pigmented; similarly, most examples of couples are limited to heterosexual partners. Such a limited description of normal inadequately prepares students to work with diverse patients and risks 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 may present images of gums of different normal pigmentations. Similarly, teachers can strive to craft cases that are varied with regard to race, religion, sex, gender, and other domains of identity.
3. 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 discuss how disease presentations may vary across populations. In the example above, the educator can discuss challenges of identifying skin color changes in persons with darker skin and recommend focusing on 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.
4. 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 as shorthand for highest risk (e.g. men who have sex with men or young people). This shortcut may inadvertently lead 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.
Solution: Consider using diverse case examples that illustrate both populations at highest risk (guided by evidence-based knowledge of population prevalence) while avoiding the impression that only those populations are at risk.
For instance, consider discussion of a geriatric person with an STI or 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.
Further, consider discussing structural reasons behind high prevalence in populations - such as discrimination.
5. Explore structural reasons for differences in health outcomes
Example: The medical literature now describes many examples of health disparities by race, socioeconomic status, and other variables. However, the mediators of those disparities are not always known and, if known, are not always discussed. This may leave some students with a misguided impression that genetic or biological differences drive such disparities.
Solution: Clarify potential reasons for racial health disparities. Conversations that focus on the structural reasons for health outcomes (e.g. racism, education, housing, immigration status) may help students move from the misguided notion that genetic/biological differences between “races” drive such health disparities to developing a more nuanced understanding of how structural racism, socioeconomic status, unconscious bias, and other factors impact health care. (Please see Addendum A for further discussion of this topic.)
6. Acknowledge limitations of research.
Example: It is common to encounter medical studies that disproportionately enroll men or white people. The generalizability of those findings to women, persons of color, or other underrepresented populations may be limited or problematic.
Solution: If underrepresentation in study subjects by gender identity, sex, race, socioeconomic status, or another meaningful variable may limit the study’s generalizability, consider disclosing this as an educational point.
This may encourage students to engage in the challenges in applying research findings to diverse populations. Dialogue may be encouraged even when study subjects across groups appear represented, because categories are often poorly defined (e.g., using a sample of a Yoruba population in Nigeria to compare “Africans” to “white Americans”). Even when racial minorities are included in research, the categorization of broad racial groups (e.g. African American, Asian) can often obscure precise outcomes, making it important for educators to consider when data disaggregation is appropriate.
Examples of Domains of Identity
- Ability (mental, emotional, and physical)
- Socioeconomic class
- National origin and geography
- Culture and behavior
- Political and religious views
The social construction of race (continued)
A key principle that informs our approach to promoting an anti-bias, anti-racist, and inclusive curriculum is that race is a social constructs (in contrast to biologic phenomena such as skin pigmentation). Racial categories (i.e., “black” or “white”) reflect social conventions rather than meaningful biological distinctions.
Race does not describe an individual’s genetic makeup. Of two people who identify as Black, one may have biologic ancestry that confers increased risk for genes that cause hemoglobinopathy while the other does not; one may have skin of Fitzpatrick Type VI (deeply pigmented) while the other has skin of Fitzpatrick Type I (pale and prone to sunburn).
It is important to understand and convey race as a social construct to avoid perpetuating the false notion that differences in health outcomes along racial lines are due to biological differences between races and genders.
For instance, the higher risk of death from prostate cancer among black patients compared to white patients is better explained by poorer access to high quality preventive and uro-oncologic care than by a difference in prostatic histology or pathophysiology. Racism, rather than race, is a risk factor.
An anti-racist framework that identifies race as a social construct and emphasizes structural reasons for health and disease helps educators convey to their students a more accurate understanding of the structural inequities that drive many of the disparities that exist and a better understanding of the role of biologic or genetic differences when they are important.
The social dimensions of gender
Gender is rooted in socially constructed roles, behaviors, expressions, and identities of girls, women, boys, men, and gender non-binary people. In fact, the relationship between gender and an individual’s genetic makeup may be overdetermined.
For example, of two people who identify as women, one may carry a Y chromosome while the other does not; one may have a uterus or ovaries or breasts or a penis while the other does not.
The portrayal of gender as distinct from biological phenomena such as genitalia or chromosomes allows educators to be specific in their descriptions of medical findings and treatments. This, in turn, gives students a clearer understanding of the potential differences in findings or recommendations for different groups of people.
If you wish to learn more, here is a partial list of resources for further reading and examples.
- Excellent overall review article: https://www.nejm.org/doi/full/10.1056/NEJMms2025768
- Inclusive Pathology: It can be difficult to find examples of pathology on skin of color. 2 resources are:
- VisualDx in UpToDate has a skin of color feature
- Ford, Chandra L., and Collins O. Airhihenbuwa. "The public health critical race methodology: praxis for antiracism research." Social science & medicine 71.8 (2010): 1390-1398.