THE BIAS CHECKLIST

The Upstate Bias Checklist is a free, publicly available tool that anyone can use when developing or reviewing content for learners at any level in the health professions. It is designed to avoid burdening learners with the responsibility to call attention to biased material, although it can and has been used by learners to provide feedback on content and educational experiences. It is expressly not intended to be punitive toward educators, but instead to promote self-reflection, faculty development and quality improvement in education, while also preventing the harm that comes when biased content reaches learners—harm that not only impacts our learners but also impacts their and our future patients.


Use the Upstate Bias Checklist →

 

Frequently Asked Questions

  • The Bias Checklist was designed for educators to use when developing or reviewing content for learners in medicine and the health professions. The intent is that the tool be self-explanatory and suitable for self-assessment. That is, it neither requires nor replaces other approaches to faculty development and continuing education, including the hard work of confronting our own biases.

    The Bias Checklist was also intended to avoid burdening learners—especially learners of color and those from other minoritized backgrounds—with the responsibility to call attention to biased material, although it can and has been used by learners themselves to provide feedback on content and educational experiences.

    It is expressly not intended to be punitive toward educators, but instead to promote self-reflection, educator development and quality improvement in education, while also preventing the harm that comes when biased content reaches learners—harm that not only impacts our learners but also impacts their and our future patients.

  • Anyone can complete the Bias Checklist, including content creators (e.g., educators writing and giving lectures, designing case-, team- or problem-based learning sessions, etc.); curriculum supervisors (e.g., unit, course or clerkship directors; evaluation and assessment leaders; deans); session facilitators (e.g., small group facilitators); and learners themselves. At the start of the Checklist, you will be asked to identify your role relative to the content you are assessing.

    Although the Checklist was originally intended for self-assessment of material, having multiple individuals assess the same content can be very useful.

  • The Checklist can be applied to any type of prepared health professions education content, including but not limited to: lecture slides or notes, clinical vignettes, multiple-choice questions, case-based learning materials, objective structured clinical examinations (OSCE), and standardized patient encounter (SPE) scripts.

    It can be used in any health profession and at all levels of training. As of January 2023, the Bias Checklist has been utilized in undergraduate, graduate and continuing medical education, nursing education, and physician assistant programs, and has even been adapted for use in clinical laboratory sciences and veterinary education.

  • Faculty who teach multiple sessions (including multiple lectures) can choose whether to submit one Checklist or separate Checklists. The Checklist does ask whether the user is evaluating one session or multiple sessions, and how many contact-hours are covered.

    We recommend a single Checklist only if the lectures or sessions are closely related; a lecturer who gives two lectures on very different topics within the same unit (for instance, one that is very biochemistry-heavy and one that is a clinical correlation) would be better served by completing two Checklists.

    Multiple cases should be evaluated individually, using the checklist, and collectively using the “Clinical Case Tracker” grid embedded in the checklist (under “Clinical Vignettes”).

  • The Bias Checklist is most effective when completed in advance of the educational session, with enough time allotted to allow for changes to be made to the content. However, it can also be completed retrospectively, as part of a review prior to the next iteration of the unit, course or clerkship.

  • Congratulations! You used the Checklist successfully.

    If the possibility of bias is detected, you will see a box telling you that your content is at risk for bias and recommending you consider making a change. Changes might include:

    Removing the content entirely (e.g., an image that promotes stereotypes of certain patient groups or an inappropriate joke)

    Replacing the content (e.g., replacing some slides of white skin with more representative slides of many skin colors, replacing outdated or offensive terminology with more appropriate language)

    Adding additional material to the content (e.g., including women and people of color in a lecture on the history of medicine, discussing why a race-based disease association might exist)

    Attaching an apology or disclaimer to the content (e.g., acknowledging that race-based GFR corrections are not based in science but may appear on standardized tests—please note that this is a last resort if none of the other approaches can be applied).

    You may not be sure what type of change to make or even if a change is definitely needed. That is completely understandable and expected. Please feel free to reach out to colleagues, expert faculty at your own institution, including your Office of Diversity, Equity and Inclusion, and/or to Dr. Caruso Brown (brownamy@upstate.edu) for additional assistance.

  • Bias in health professions negatively impacts learners by creating a learning environment that is unsupportive and even hostile to learners from traditionally underrepresented backgrounds, hindering their success. However, it has an even greater effect on learners’ future patients. Health professions students and trainees who learn biased material (for instance, suggesting that race is a biological, rather than social, construct) are more likely to treat their patients differently based upon their social identities—missing diagnoses that don’t fit stereotypes, under-managing pain and other symptoms, leaving patients feeling unheard amd disrespected, and increasing mistrust in the healthcare system. Every interaction between health professions educators and learners is an opportunity to begin to dismantle the bias and structural oppression embedded in our society. What you teach today—even if it seems very far removed from clinical care—may change a patient’s life tomorrow.

    For more information, please listen to one the following presentations:

    Short version (< 10 minutes)

    Long version (60 minutes): [coming soon]

  • By utilizing the public-facing version of the Bias Checklist that is accessible through this website (hosted on REDCap), you are agreeing to allow Dr. Caruso Brown and the Bias Checklist Collaborative to retain your responses for analysis, possible publication and continuous quality improvement of the Checklist. Identifying information is not collected.

    If you are using a version made available through your institution, you should contact your local Bias Checklist Collaborative leader for further information. (A list of Bias Checklist Collaborative member institutions and contacts is available here.) At SUNY Upstate, for example, individual Checklists and pooled data on Bias Checklist utilization (proportion of checklists completed relative to the number of hours of content taught and proportion of changes mind relative to the frequency of changes recommended) for each unit, course and clerkship are provided to the directors prior to the annual review each year.

  • The Bias Checklist was designed by Dr. Amy Caruso Brown at SUNY Upstate Medical University, and she holds the copyright to this tool. Please feel free to contact Dr. Caruso Brown (brownamy@upstate.edu) with any questions or feedback.

    It was informed by a review of the literature, synthesized with three years of student evaluation data from SUNY Upstate Medical University, and is regularly revised to include new material. The current version of Bias Checklist includes 13 domains identified as being at risk for bias or promotion of shame, stereotype or stigma: Race and Ethnicity, Gender, Sexual Orientation and Sexuality, Disability, Mental Health Including Substance Use, Weight, Immigration Status, Poverty, Religion, Prisoners, and Interprofessional Communication; and two types of content which are especially prone to bias: visual images and clinical vignettes. More information regarding each domain is available here.

    More information regarding the history of the Bias Checklist is available here.

  • A complete list of publications and presentations related to the Bias Checklist is available here.

    Caruso AB, Hobart TR, Botash AS, Germain LJ. Can a checklist ameliorate implicit bias in medical education? Medical Education. 2019;53(5):510.

  • Please contact Dr. Caruso Brown at brownamy@upstate.edu about creating a Friends of Upstate REDCap account and a REDCap project with the checklist for your institution, which will give you both the ability to edit the checklist and access to data from your own faculty. Dr. Caruso Brown is also available to lead faculty development workshops and can provide additional information regarding institution- or program-wide implementation and monitoring.

    More information regarding support for implementation of the Bias Checklist at the program or institutional level is available here.

Checklist Glossary

  • Ableism: “Discrimination and social prejudice against people with disabilities and/or people who are perceived to be disabled; ableism characterizes people who are defined by their disabilities as inferior to the non-disabled [and] assign[s] or denie[s them] certain perceived abilities, skills, or character orientations” (Wikipedia)

  • Access to care: “The timely use of personal health services to achieve the best health outcomes” (IOM, 1993); includes the 4 components of insurance “coverage (facilitates entry into the healthcare system; uninsured people are less likely to receive medical care and more likely to have poor health status), services (having a usual source of care is associated with adults receiving recommended screening and prevention services), timeliness (ability to provide health care when the need is recognized), and workforce (capable, qualified, culturally responsive providers)” (Healthy People, 2020)

  • Allostatic load: “Wear and tear on the body” that accumulates as an individual is exposed to repeated or chronic stress (McEwan, 1998), including the stress of racism, resulting in cumulative negative mental and physical health effects

  • Bias: Preconceived opinion or inclination that is not rigorously based on reason, experience or evidence (though it may have roots in these things); can be positive, negative or both; occurs on a spectrum from implicit (or unconscious) to explicit (or consciously endorsed)

  • Binary (gender): The idea that human gender is divided into two distinct sexes, female and male, typically associated with distinct gender roles

  • Cisgender: Describes a person whose gender identity aligns with those typically associated with the sex assigned to them at birth (Human Rights Campaign)

  • Cognitive disabilities: Limitations in mental functioning affecting skills such as communication, self-help, or social interaction and cause greater difficulty with such tasks than experienced by people defined by society as “average” or “typical”

  • Cultural humility: “Ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [other person]”; focuses on self-humility rather than achieving a state of knowledge or awareness regarding culture (Tervalon and Murray-Garcia, 1998)

  • Culture: Values, beliefs, systems of language, communication, and practices that people share in common and that can be used to define them as a collective; also includes the material objects that are common to that group or society (https://www.thoughtco.com/culture-definition-4135409)

  • 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)

  • Discrimination: Unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age or sexual orientation (APA)

  • Diversity: Representing or acknowledging all aspects of human differences including but not limited to socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography (including rural and highly rural areas), disability, and age (AAMC)

  • Equity: Absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically (WHO)

  • Health equity: Achieved when every person has the opportunity to "attain his or her full health potential" and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances”

  • 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)

  • Explicit biological differences: Health differences among different racial and ethnic groups that are attributed to differences in the distribution of genes, often falsely; the vast majority of health differences are not genetic in origin but are due to social and structural inequity, although biology (through mechanisms such as toxic stress and epigenetic modification) may play a role

  • 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.

  • Gender role: How a person is expected to act, speak, dress, groom, and conduct oneself based upon assigned sex or gender identity and within a particular culture, community and/or society

  • 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

  • Geriatric: Of or relating to the process of growing old and the medical care of old people

  • Health disparities: “Differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups, compared with the general population susceptible to those conditions” (NIH, 1999)

  • Health outcomes: Health outcomes measure a change in the health status of an individual or a group which can be attributed to intervention.

  • 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

  • Implied biological differences: The suggestion or implication (not overtly stated) that disparities in the health status or health outcomes of different racial and ethnic groups is due to genetic differences rather than social and structural inequity

  • Inclusion: The practice or policy of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those who have physical or mental disabilities and members of other minority groups.

  • Inequity in healthcare: Systematic differences in the opportunities groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes (Braveman, 2006; WHO, 2011).

  • Intersectionality: Interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage, as well as privilege and advantage (Williams Crenshaw, 1989)

  • Intersex: Individuals born with physical sex markers (genitals, hormones, gonads, or chromosomes) that are neither clearly male nor female

  • Judgment: An opinion; in this context, an opinion formed by a healthcare professional regarding the quality of a patient’s decisions, behaviors, lifestyle, etc., often based upon the professional’s own beliefs and values rather than the patient’s

  • Marginalization: Process of making a group or class of people less important or relegated to a secondary position.

  • Mass incarceration: Extremely high rate of incarceration in the United States for both adults and youth, especially Black adults and youth. 

  • Mental health: Emotional, psychological, and social well-being; affect how we think, feel, and act; helps determine how we handle stress, relate to others, and make choices

  • Migrants: Previously used to designate people who move by choice rather than to escape conflict or persecution, usually across an international border; increasingly used as an umbrella term to refer to any person who moves away from their usual place of residence, whether internally or across a border, and regardless of whether the movement is ‘forced' or voluntary

  • Misogyny: “Contempt for, or prejudice against women or girls; enforces sexism by punishing those who reject an inferior status for women and rewarding those who accept it” (Wikipedia/Kate Manne)

  • Monolithic: Intractably indivisible and uniform; in this context, refers to the tendency to perceive all members of another cultural or religious group (especially an unfamiliar group) as sharing the same values, beliefs and practices, despite all such groups having significant intra-group variation

  • Neurodiversity: Variation in the human brain regarding sociability, learning, attention, mood and other mental functions (Singer, 1998); often used by advocates to discuss the value in different ways of thinking, such as those experienced by autistic people

  • Physical disabilities: Limitation(s) on a person's physical functioning, mobility, dexterity or stamina; may include or be distinguished from impairments in vision or hearing; typically distinguished from intellectual or cognitive disabilities and psychiatric disabilities

  • 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.

  • Prisoners: People deprived of liberty and kept under involuntary restraint, confinement, or custody; especially those on trial or in prison; a vulnerable group accorded additional protections under federal research regulations (OHRP, 2021)

  • Quality of life: Measure of health, comfort, and happiness experienced by an individual or group; highly individual and subjective with many studies showing that people routinely underestimate the quality of life reported by those they perceive as other (for example, disabled people self-report higher quality of life than able-bodied report when asked about what it would be like to have a disability)

  • 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

  • Racism: “Prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is a minority or marginalized” (Dictionary.com)

  • Refugee: “Person who has fled their own country because they are at risk of serious harm” (including human rights violations and persecution); the risks to their safety and life were so great that they felt they had no choice but to leave and seek safety outside their country because their own government cannot or will not protect them from those dangers; refugees have a right to international protection (Amnesty International, 2021)

  • 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)

  • Sexism: Prejudice, stereotyping, or discrimination, typically against women, on the basis of sex

  • Sexual behavior: Manner in which humans experience and express their sexuality

  • Sexual orientation: “An enduring pattern of romantic or sexual attraction (or a combination of these) to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender; generally subsumed under heterosexuality, homosexuality, and bisexuality, while asexuality (the lack of sexual attraction to others) is sometimes identified as the fourth category” (Wikipedia)

  • Sexuality: Capacity for sexual feelings

  • Shame: In the healthcare context, more accurately termed “medical shaming”; process by which patients are judged by healthcare professionals to be more responsible for their own situation (including their health, social and economic status) and less deserving of health and healthcare than the “ideal” patient (Serani, 2019)

  • Social determinants of health: “Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (IOM, 1999)

  • Social structures: “Policies, economic systems, and other institutions (judicial system, schools, etc.) that have produced and maintain modern social inequities as well as health disparities, often along the lines of social categories such as race, class, gender, sexuality, and ability” (Hansen & Metzl)    

  • Socioeconomic status: “Social standing or class of an individual or group”; “often measured as a combination of education, income and occupation” (APA, 2021)

  • Spectrum (gender): Continuum of identity and expression stretching from men to women and masculine to feminine; concept that better reflects most people’s lived experience, as no one has exclusively masculine or exclusive feminine traits, interests, etc. 

  • Spectrum (sexual orientation): Model of sexual orientation “which places people whose sexual and/or romantic orientation is toward persons of the same gender and/or sex—gay, lesbian and same-gender-loving people—at one end and people whose sexual and/or romantic orientation is toward persons of the other binary gender or sex—straight people—at the other end”; in this model, people who are sexually and/or romantically attracted to both men and women and/or non-binary people are in the middle (University of South Dakota, 2021)

  • Stereotype: Fixed, overgeneralized and oversimplified image or idea of a particular type of person or thing; often widely held and applied to whole groups of people

  • Stigma: “Powerful social process characterized by labeling, stereotyping, and separation, leading to loss of social status and discrimination, all occurring in the context of power”; in the context of healthcare, stigma can be related to living with a specific disease or health condition and is often associated with judgment or blame regarding the condition; a barrier to healthcare (Nyblade, et al., 2019)

  • Structural competency: “Trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health” (Hansen and Metzl, 2017)

  • Structural humility: Approach which “cautions providers against making assumptions about the role of structures in patients' lives, instead encouraging collaboration with patients and communities in developing understanding of and responses to structural vulnerability” (Metzl and Hansen, 2014) 

  • Structural violence: Form of violence wherein some social structure or social institution may harm people by preventing them from meeting their basic needs (Galtung, 1969)  

  • Structural vulnerability: “Risk that an individual experiences as a result of structural violence, including their location in multiple socioeconomic hierarchies; not caused by, nor can it be repaired solely by, individual agency or behaviors” (Bourgois, Holmes, Sue, and Quesada, 2017)

  • Systemic racism: Form of racism that is embedded through laws and regulations within society or an organization; also called institutional or structural racism (see Camara Jones’ essay “Levels of Racism”)

  • Substance use: Use of drugs or alcohol, and includes substances such as cigarettes, illicit drugs, prescription drugs, inhalants and solvents; distinguished from a substance use disorder 

  • Substance use disorder: Persistent use of substances despite substantial harm and adverse consequences

  • Traditional gender role: Roles that support or promote the gender binary and align with older notions of what is acceptable for women or for men (for example, women as nurturers, stay-at-home wives and mothers, etc.; men as physically aggressive, protectors, financial breadwinners, etc.; in healthcare, may include assumptions that women are nurses and men are doctors, not vice versa)

  • Transgender: Person whose gender identity and/or expression is different from the gender they were thought to be at birth; some transgender people may take steps to better align their sex with their gender using hormones and/or surgery, while others may choose not to do so

  • Toxic stress: See “allostatic load”, above

  • Undocumented immigrant: Anyone residing in any given country without legal documentation from that country; includes people who enter a country without inspection and permission from the government, and those who enter with a legal visa but that remain after the visa expires (Immigrants Rising, 2021)