HealthApril 13, 2023

Diversity in medical education: Creating bias-free educational materials and learning environments

A study in the New England Journal of Medicine on the role of medical schools in propagating physician bias stated that, more than a decade after the National Academy of Medicine (NAM) issued a report on unequal treatment, racial disparities in the quality of care of patients have continued or worsened. These inequalities derive from structural racism, macrolevel bias in health care institutions, and implicit bias among physicians.

During a recent episode of the Wolters Kluwer Expert Insights Webinar Series, speaker Yasmin Carter, PhD, anatomist and diversity curriculum leader at the University of Massachusetts T.H. Chan School of Medicine, discussed initiatives that deconstruct the concerns of faculty about the development of appropriate and inclusive educational materials and learning environments. Dr. Carter’s focus is on incorporating health equity, diversity, and inclusion as a lens to the entire medical curriculum with a mission in advancing health equity for underrepresented groups, including the LBGTQIA+ community.

In this presentation, Dr. Carter reviews the definitions of bias and what we can learn from our own biases, delves into the structure of diversity, equity, and inclusion (DE&I), and talks about the aspirational idea of ‘bias-free’ educational materials and learning relating to DE&I in medical education.

What is bias?

The two forms of bias applicable to medical education are implicit bias and explicit bias. With explicit bias, individuals are aware of their demonstrated intention or prejudices against others, especially towards those in marginalized groups. However, implicit bias is an unconscious and unintentional response, that still affects judgments, decisions, and behaviors. Many people are not aware of their implicit biases, but with recognition, can mitigate the impact of their biases on others.

It is important to understand everyone holds biases, they are multifactorial and should be addressed when they have the potential to impact others. Often, in reference to DE&I, bias is thought of as specific to racialized groups and the LGBTQ+ communities. While the impact on these groups may be greater, bias can be prompted by hundreds of different factors, such as age, appearance, immigration status, and socioeconomic status, and many of these factors overlap. This overlapping is called ‘intersectionality’.

What is DE&I?

As commonly as the terms diversity, equity, and inclusion are used, there remains a lost sense of what they refer to on their own. To summarize, diversity is what makes everyone different from each other, including race, sex, gender and gender identity, religion, political beliefs, etc. Equity is the promotion of justice, fair treatment, and the recognition and dismantling of systems of racism and oppression. Inclusion is the creation environment where all individuals’ identities, perspectives, ideas, and beliefs are valued and respected.

When thinking about these definitions in relation to bias, DE&I is how we address and negate bias. In other words, bias is what makes diversity an issue that must be addressed, thus creating inequities. In terms of medical education, there needs to be an established foundation of student knowledge addressing DE&I in the curriculum. In doing so, students are more prepared as knowledgeable professionals for their patients, their colleagues, and themselves.

DE&I in medical education

Since bias is carried by everyone, there can never truly be bias-free learning materials, however educators can set the tone to aim to do so and address diversity in a way that allows equity and improves the environment of inclusion. One way for educators to implement this is through language. DRIVE, which stands for Diversity, Representation, and Inclusion for Value in Education, is a UMass Chan initiative geared towards faculty development with tools designed to support addressing implicit bias for the creation of resources for the goal of a bias-free education. Improving terminology and language used in education requires practice and research as updates are made in medical fields, constantly.

The Association of American Medical Colleges (AAMC) also released recommended guidelines, and a topic introduced was on the improvement of terminology that is used across medical education, ensuring the language is appropriate, and used in the proper places and settings. This improvement can have a massive impact on both faculty and student educational experiences, as well as on future generations of patients.

Images used in presentations and educational resources is another area to improve learning materials and environments. Images can invite connection, promote recognition, and improve diagnoses across patients of all different skin tones, while reducing bias of the range of body types. A study was conducted that looked at medical education textbooks which showed that approximately 4.5% of the images illustrated represented individuals with dark skin tones. In the United States, 12.4% of the population is made up of individuals with darker skin tones which correlates to 41.1 million people in the Unites States who are not represented in medical textbooks. Images of disabled people, and individuals with larger body types are rarely represented.

Creating a culture of feedback and a growth mindset are additional ways to create learning opportunities and receive constructive criticism. Modeling good behaviors and habits, listening to students, colleagues, and patients, and setting up an educational environment that is open to constructive feedback are ways for educators to grow and become mindful of what they are teaching and improvements that are needed in aiming for a bias-free educational experience.

Watch the webinar recording, “Diversity in medical education: Creating bias-free educational materials and learning environments.”

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