Moving Beyond the Checklist

Ready to do more than just mitigate bias in individual content? Below are resources to help you and your institution take the next steps.

 

Improving the quality of case studies and clinical vignettes

Bias in content is sometimes only detectable as part of a larger pattern, especially patterns in case studies and clinical vignettes (including those used on examinations). [1-3]

For example, students at Case Western Reserve University noticed that clinical vignettes in which patients were described as having a substance use disorder will more likely to have poor outcomes (including the death of the patient in the vignette) than other types of clinical vignettes; while students at SUNY Upstate noticed that the majority of case studies involving patients described as Spanish-speaking also described those patients as being migrant farmworkers. This is especially challenging in undergraduate medical education, where curricular efforts are often fragmented or siloed.

To address this, we developed a tool that can be used to track cases and vignettes across examinations, courses, curricula and degree programs. The tool is available as a spreadsheet to download or Google Sheet to duplicate.

Watch a video about this: “The Big Picture: Assessing Cases, Courses and Curricula”

Other resources for improving case-based teaching:

Selected references:

  1. Lee CR, Gilliland KO, Beck Dallaghan GL, Tolleson-Rinehart S. Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions. BMC Medical Education. 2022;22(1):585. https://link.springer.com/article/10.1186/s12909-022-03665-4

  2. Ripp K, Braun L. Race/ethnicity in medical education: an analysis of a question bank for step 1 of the United States Medical Licensing Examination. Teaching and Learning in Medicine. 2017;29(2):115-22. https://www.tandfonline.com/doi/pdf/10.1080/10401334.2016.1268056

  3. Marjadi B, Chiavaroli N, Sorinola O, Milos Nymberg V, Joyce C, Parsons C, Ryan A. Diversity audit of medical school examination questions. Teaching and Learning in Medicine. 2023 Jul 24:1-9. https://www.tandfonline.com/doi/pdf/10.1080/10401334.2023.2240776

INTEGRATING HEALTH EQUITY IN CURRICULA

Medical schools can reduce health disparities by teaching students about social determinants of health and health equity. For instance, in 2021, the Wake Forest School of Medicine piloted a longitudinal health equity curriculum that included experiential learning opportunities. This curriculum improved student’s knowledge of health equity and their confidence working with underserved groups. [1]

One framework guiding health equity curricula is the idea of cultural humility: a commitment to treating patients as experts about their experiences, thereby equalizing power imbalances in the physician-patient relationship. Cultural humility centers self-reflection so that students can examine their assumptions. [2] There are a variety of activities and guidelines for fostering cultural humility. [3]

Other resources for integrating health equity across curricula:

Selected references:

  1. Denizard-Thompson N, et al. Association of a Health Equity Curriculum With Medical Students’ Knowledge of Social Determinants of Health and Confidence in Working With Underserved Populations. JAMA New Open. 2021 Mar;4(3):e210297. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921901/

  2. Solchanyk D, et al. Integrating Cultural Humility into the Medical Education Curriculum: Strategies for Educators. Teaching and Learning in Medicine. 2021;33(5):554-560. https://www.tandfonline.com/doi/full/10.1080/10401334.2021.1877711

  3. Frond C, et al. Cultural Humility Toolkit. Nurse Educator. 2022;47(5):267-71. https://journals.lww.com/nurseeducatoronline/Fulltext/2022/09000/Cultural_Humility_Toolkit.4.aspx?context=FeaturedArticles&collectionId=5

ADDRESSING BIAS IN EVALUATION AND ASSESSMENT

Biases impact both the design and interpretation of assessments. While the Bias Checklist can be used to evaluate exam questions (independently or grouped) and case-based assessments including simulations, writing prompts and other assessments, behaviorally-based or workplace-based assessment are also subject to biases and require other approaches and tools. For example, researchers have noted that language used in clerkship evaluation often reflects “students’ personal attributes rather than competency-related behaviors” and that even when students receive the same grade, narrative evaluation language differs “by gender and URM status.” [1-4]

Other resources for improving evaluation and assessment:

Selected references:

  1. Klein R, Julian KA, Snyder ED, et al. Gender bias in resident assessment in graduate medical education: review of the literature. Journal of General Internal Medicine. 2019;34:712-9. https://link.springer.com/article/10.1007/s11606-019-04884-0

  2. Rojek AE, Khanna R, Yim JW, et al. Differences in narrative language in evaluations of medical students by gender and under-represented minority status. Journal of General Internal Medicine. 2019;34(5):684-91. https://doi.org/10.1007/s11606-019-04889-9

  3. Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A, Moore EZ. Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations. PloS One. 2017;12(8):e0181659. https://doi.org/10.1371/journal.pone.0181659

  4. Hauer KE, Park YS, Bullock JL, Tekian A. “My assessments are biased!” Measurement and sociocultural approaches to achieve fairness in assessment in medical education. Academic Medicine. 2023 Apr 21. https://pubmed.ncbi.nlm.nih.gov/37094278/

ADDRESSING BIAS IN THE LEARNING ENVIRONMENT AND HIDDEN CURRICULUM

Aspects of the learning environment and hidden curriculum can reinforce or increase bias in students. Some ways of reducing these types of biases include increasing awareness of negative stereotypes, working to eliminate these stereotypes, and promoting perspective-taking. For example, one study found that the strongest predictors of positive implicit attitudes toward LGBT+ individuals were frequent and positive contact with people who identified as LGBT+. [1,2]

Other resources for improving the learning environment:

Selected references:

  1. Joseph OR, et al. Understanding Healthcare Students’ Experiences of Racial Bias. Int. J. Environ. Res. Public Health. 2021;18(23). https://www.mdpi.com/1660-4601/18/23/12771

  2. Fallin-Bennett K. Implicit Bias Against Sexual Minorities in Medicine. Academic Medicine. 2015 May;90(5):549-552. https://journals.lww.com/academicmedicine/fulltext/2015/05000/Implicit_Bias_Against_Sexual_Minorities_in.8.aspx