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Applying Inclusive Teaching Principles to Clinical Education

Student populations at institutions of health education are increasingly more diverse. Inclusive teaching practices unlock the full benefits of this diversity by creating an environment where different perspectives can be leveraged to enhance learning and promote identity development of future health professionals. 

Educators working in the clinical environment face unique challenges when implementing inclusive teaching practices. This resource is intended to support clinical educators in applying the five research-based principles of inclusive teaching, described in the CTL’s Guide for Inclusive Teaching at Columbia, to the clinical setting. For each principle presented in the guide this resource provides:​

  •  A summary of the principle. Since each principle is supported by a robust body of literature, this resource summarizes each principle to be more digestible. Educators may wish to explore these principles in greater depth which is why each summary is supplemented with links to the CTL’s Massive Open Online Course (MOOC), Inclusive Teaching: Supporting All Students in the College Classroom.
  • A set of clinical corollaries. Developed from the health education research literature, these corollaries elaborate on each principle to help educators apply the principle in their clinical teaching.
  • Research based strategies. Each corollary is accompanied by a set of strategies educators can implement to promote an inclusive learning environment. that creates a sense of belonging for trainees regardless of gender expression, gender identity, sexual orientation, age, ability, race, skin tone, ethnicity, and religion.

This resource defines clinical teaching broadly in order to be inclusive of all health professions and the diverse ways that teaching and learning occur in the clinical setting. The strategies provided cover a range of clinical environments and scales so all educators, such as faculty, preceptors, residents, attendings, supervisors and even individuals without formal teaching roles, can apply inclusive teaching principles to their interactions with trainees in the clinical setting. 

This resource is also meant to be accessible to clinical educators regardless of their level of experience in diversity, equity and inclusion efforts. This resource utilizes terms from DEI research in the health sciences. The University of North Carolina Medical School has created a Glossary of DEI terms that can be helpful for all educators when utilizing this resource. It is important to note that while there is certainly overlap between inclusive teaching practices and anti-racist pedagogies, they are not interchangeable. Inclusive teaching practices do not always address systemic inequality, nor do they automatically encompass the healing, decolonization, and justice-oriented work of anti-racist teaching practices. 

On this page:

Principle 1: Establish and support a class climate that fosters belonging for all students.

Principle 1 in the Guide for Inclusive Teaching at Columbia stresses the relationship between a trainee’s sense of belonging and their performance. Inclusive teaching requires creating a welcoming environment that values and respects trainees’ identities, experiences, and viewpoints (Barr, 2016). This goes beyond the structure and content of the course and requires educators and learners to combat behaviors that invalidate the experiences of others, particularly for those from marginalized backgrounds (Gross-Davis, 2009). Dr. Michele DiPietro, describes the importance and challenges to creating an environment that explicitly centers diverse experience and viewpoints.

Clinical Corollary 1.1 – Create a supportive learning environment that treats diversity as an asset in health care.

Every trainee carries with them different experiences, lived realities, cultural knowledge, and histories (Tachine et al., 2017). These prior experiences can be viewed as pieces to a larger puzzle that can be collectively utilized to solve health care problems of a wider range of patients. Focusing on trainee’s experiences as assets avoids privileging a single type of trainee experience and allows trainees to view their personal identities as valuable. 

Suggested Strategies:
  • Build educator-trainee rapport.

Trainees may not always share their struggles or the barriers they face, which can make it difficult to know what they need. Educators can model a level of openness by getting to know trainees, learning their names, pronouns, interests, and learning processes. When educators share their own struggles, it can create a space where trainees feel comfortable in sharing their own and break down barriers to learning. 

  • Invite trainees to share their experiences without tokenizing them by expecting them to educate others.

Inclusive educators strive to understand the diverse identities and experiences of their trainees and welcome their trainees to share them in order to add layers of complexity to the discussion of health issues without making assumptions about their identities. However, it is important that this sharing be voluntary. Requiring trainees to educate others about the struggles of people who may share their identities can reinforce stereotypes, add additional cognitive burdens to trainees from historically marginalized identity groups, and create feelings of isolation by highlighting their identities as different or “other.”

  • Increase collaboration and lower competition.

When trainees are able to work collaboratively to solve problems, they develop more robust and thoughtful solutions and learn how different perspectives can improve patient care. Educators can build this rapport by providing opportunities for trainees to interact with each other and build relationships rather than promoting an individualistic mindset in a competitive learning environment. 

Clinical Corollary 1.2 – Work to address barriers to inclusion in the clinical setting.

Trainees from groups historically excluded from health care professions experience barriers throughout their training (Sandoval et al., 2020). It is up to educators to create a learning environment that reduces the impact of these barriers on learning. In the clinical setting, this can be difficult because educators do not always have control over every interaction. For instance, patients may say or do things that contribute to marginalization. The goal is not to guarantee a safe space for trainees but rather to take steps to actively counter the feelings of exclusion these kinds of negative interactions create so trainees feel their experiences are seen, valued, and respected.

Suggested Strategies:
  • Speak up if you witness bias from patients, trainees, or colleagues. 

Educators set the tone for an inclusive learning environment by actively addressing microaggressions, alienating comments, and offensive behaviors in the clinical environment regardless of their source (da Silva et al., 2022; York et al., 2021). These strategies include:

    • Assess: Every situation is different. When you witness an incident of bias, consider the following elements of the situation to determine how to act:
      • How is this situation impacting the physical & emotional safety of all individuals?
      • Should the situation be addressed in the moment or afterwards? 
      • What is the best strategy for interrupting the interaction? 
      • How do I preserve the dignity of the individuals? 
    • Respond: Confront or distract the source of the bias to establish boundaries and de-escalate the situation. You may need to seek help from a third party. Document or report the incident
    • Support: Once the situation has been diffused, check in on the wellbeing of the recipient of bias to and demonstrate you are there to support them.
  • Create community agreements and discussion guidelines that include respectful behavior and inclusive language.

Community agreements are sets of guidelines educators create with their trainees which foster an atmosphere of mutual respect and collaborative inquiry. Community agreements set participation norms, help clarify expectations, cultivate a sense of belonging among trainees, and facilitate trainees’ ability to engage productively with one another across their differences. Educators can start creating these agreements on the first day by either giving trainees a set of predetermined community guidelines, or by developing them with the trainees.

Principle 2: Set Explicit Expectations. 

Principle 2 in the Guide for Inclusive Teaching at Columbia emphasizes the importance of clearly defining learning goals for all trainees. Educators should avoid assuming trainees’ familiarity with learning expectations, as this may inadvertently favor trainees from particular backgrounds. Dr. Michele DiPietro discusses how setting expectations before, during, and after class can contribute to an inclusive learning environment.

Clinical Corollary 2.1 – Orient the learner to the clinical setting.

The process of moving into a new clinical experience is a learning period shaped by the particulars of both the setting the trainee is coming from and the new setting (Kilminster, 2011). Since every trainee has a different approach to their learning they may need to develop new ways of engaging to better align with the expectations of the specific environment they are entering. Communicating the values, beliefs, and norms which frequently go unspoken can reduce the amount of time trainees need to acclimate to the clinical setting and ensure all trainees are prepared to learn.

Suggested Strategies:
  • Help trainees to acclimate to each clinical environment.

Even trainees who have been in other clinical environments can benefit from explicitly learning about the expectations of the specific clinical environment they are entering. Intentionally helping trainees adapt to each clinical environment, both before and throughout the clinical experience, levels the playing field for all learners.

  • Describe what you would like the trainee to learn while they are on the clinical rotation.

Trainees, as novices in the field, are not always experienced enough to identify what elements of an experience are relevant and important, and which are not. By explicitly calling out important elements of the clinical experience, educators ensure all trainees learn from each patient encounter.

  • Articulate competencies trainees should develop in their clinical experience and criteria by which they will be assessed.

Trainees may not see how each patient experience relates to the clinical competencies they are evaluated against. Educators can provide this greater perspective by making space for the trainees to explicitly discuss how individual patients and clinical experiences connect to the overall clinical competencies.

Clinical Corollary 2.2 – Model expected behavior.

Educators, intentionally or not, are modeling expected behaviors to their trainees. This includes not just health care practices but how to learn from the clinical experience through self reflection and feedback. It is important to model the types of interactions you expect trainees to have with patients and other members of the interprofessional care team.

Suggested Strategies:
  • Acknowledge challenges and normalize mistakes.

Trainees often struggle in silence. Acknowledging areas that are historically difficult for trainees can reframe struggle not as a failure but as part of the learning process. This promotes a growth mindset which can help trainees persist through struggle. 

  • Set aside time for debriefing and feedback before, during, and after the clinical encounter. 

Detailed and prompt feedback on clinical performance, and opportunities to improve, are necessary to help the trainee recognize strengths, identify areas of weakness, and develop plans for improvement. The CTL’s Effective Feedback in Clinical Education resource provides additional details on how educators can meaningfully incorporate feedback into the clinical learning environment.

  • Provide examples of exemplary work.

Examples of good work come from many places, including the trainees themselves. Highlighting these examples encourages trainees to learn from one another, raises their self-efficacy, and articulates standards and learning objectives. 

Principle 3: Select course content that recognizes diversity and acknowledges barriers to inclusion.

Principle 3 stresses the importance of unbiased, holistic representation of diversity in course content. Learning experiences that fail to represent diversity by omitting or falsely representing identities have a significant impact on trainees’ feelings of belonging at a time when they are developing their sense of identity, purpose, and competence in the field (Ambrose, 2010). Dr. Bryan Dewsbury provides a powerful example of how the content can inadvertently reinforce problematic views that contribute to systematic oppression. Clinical educators may not have control over what cases the trainees see, but they do have control over how the trainees engage with the case material. The way content is presented can reinforce problematic stereotypes and repeat patterns of exclusion in healthcare, but it also has the power to challenge stereotypes and create a more inclusive environment.

Clinical Corollary 3.1 – Extend inclusive principles to interactions with patients and other health professionals. 

In the clinical setting interprofessional and patient interactions provide additional opportunities for trainees to observe and internalize dynamics of power and privilege. Trainees who witness stigmatizing or stereotyping interactions between their clinical educators and others in the clinical setting (patients, families, health professionals, etc) may begin to feel like their identities are not valued in health care practice (Hess et al., 2020; Cerdeña et al., 2020; Amutah et al., 2021; Braun and Saunders, 2017). Trainees who witness interactions based on stereotypes may also internalize those harmful stereotypes and biases which impacts their patient care, and interprofessional interaction in the future (Amutah et al., 2021; Burgess et al., 2007). 

Suggested Strategies:
  • Recognize diversity among patients and how it can impact their care.

Individuals within the same identity group may have significant differences in the presentation of identical health concerns. Treating patients as individuals lowers the risk of misdiagnosis by ensuring trainees do not miss important factors relevant to the care of the patient by generalizing or stereotyping. Clinical educators can do this by engaging trainees in discussions about how patient identity does or does not affect symptoms, diagnosis, and treatment and by demonstrating how to collect and apply relevant patient-identified demographic data to develop a comprehensive patient health assessment and treatment plan that is culturally responsive and avoids stereotypical inferences. 

  • In the absence of diverse patients, show or discuss examples of how cases would present in patients of varied gender expression, gender identity, sexual orientation, age, ability, race, skin tone, ethnicity, and religion.

Clinical educators do not always get to choose the cases that the trainees will see due to limitations on which patients are available and willing to have trainees participate in their care. However, representing diversity in case discussions is important to challenge stereotypes and help trainees prepare for the diversity of patients they will see in their careers. 

  • Be mindful of language in the clinical environment.

Language plays a critical role in affirming identity and belonging. This is true of the language clinical educators use to address trainees, and patients. Using inclusive language in healthcare can help fight stigma, address social determinants of health, and recognize people as individuals with needs that go beyond their health conditions. According to the AAMC Advancing Health Equity language guide, inclusive language includes addressing trainees, patients and colleagues with their preferred pronouns; and using person-first language (e.g., “a person with diabetes” instead of “a diabetic” or “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).

Additionally, awareness of stigmatizing language is essential. Several studies found that negative descriptors like “difficult” or “noncompliant” occur in Black patients’ electronic health records significantly more than white patients’, indicating potential bias propagation (Sun et al. 2022; Park et al. 2021; Himmelstein et al., 2022). Even apparently neutral labels like “normal” can have a significant effect on the lives of those defined in contrast to it as abnormal, pathological, or deviant (Rost 2021). Avoiding stigmatization requires educators to consciously consider their language when addressing or discussing patients, especially in front of trainees, and expanding their concept of “healthy”.

  • Model inclusive interactions with other health professionals in the clinical setting 

Multiple studies have reported that healthcare trainees hold stereotypes about members of different healthcare professions, and these stereotypes are present when trainees enter their professional lives. These stereotypes affect interactions and communication among healthcare professionals in clinical environments (Cook and Stoecker, 2014; Ateah et al., 2010). Therefore, it is important for educators to examine how stereotypes, and bias interfere with communication and collaboration and for them to model inclusive interactions with their colleagues in the clinical environment. 

Clinical Corollary 3.2 – Consider the ways case materials challenge or reinforce forms of systemic oppression in healthcare.

Misrepresentation of race, ethnicity, gender, disability and other identities in clinical education can propagate bias and flawed assumptions about physiological differences between social identity groups. There are many examples of how these biases lead to clinical guidelines and diagnostic practices that exacerbate differential health outcomes for patients from these identity groups (Amutah et al., 2021). Through their discussions of cases and patients, educators can actively engage trainees in conversations about how systems of power, privilege, and oppression continue to influence healthcare and how the impacts can be mitigated.

Suggested Strategies:
  • Be deliberate and thoughtful when including demographic information. 

Trainees already carry with them some stereotypes about disease pathology and how it connects to different identity markers. The way demographic information is presented and discussed during the trainees clinical experience can either challenge or reinforce these stereotypes. The following questions are just some of the considerations inclusive educators make when including demographic information in a case: does including it advance patient care?; does it draw false equivalencies between biological and sociological constructs?; what assumptions will trainees make if it is included?; does including it promote stereotypes? Do I only include race when discussing patients who are not white? (Acquaviva and Mintz, 2010). The University of Central Florida has created a useful resource for revising teaching cases in health education to be more inclusive.

  • Differentiate between social determinants of health and the biology, pathology and genetics of each case. 

No rigorous scientific evidence supports using race or culture as a surrogate for genetic or heritage information (Acquaviva and Mintz, 2010). However, identity markers such as race or gender are often listed as risk factors for certain diseases when the real issues are a complex set of social and economic factors. Educators can challenge these false equivalencies by drawing clear distinctions between the biological elements of a case and the social determinants of health for each patient.

  • Critically evaluate sources of knowledge and how they treat race, gender, and other historically marginalized identities.

Historically, biomedical research has not always recruited diverse participants. This shortcoming has created gaps in the understanding of diseases and conditions, which impede the quality of health care. When assigning research papers, clinical educators can develop the trainees’ critical thinking skills by having them examine the inclusion or exclusion criteria of the research. Inclusive educators also advocate for fair representation of perspectives in biomedical research by selecting resources written and developed by racially, culturally, and linguistically diverse researchers. As part of its commitment to improving minority health and reducing health disparities the National Institutes of Health (NIH) has created useful resources on the importance of diversity in biomedical research and clinical trials.

Clinical Corollary 3.3 – Guide trainees in developing their critical consciousness. 

Preparing future health professionals to work with culturally diverse populations and address biases in health care is an essential part of health education. However, focusing on cultural competence alone creates a static view of different cultures and doesn’t account for intersectional identities. Kumagai and Lypson (2009) suggest that educating physicians skilled at addressing the health care needs of a diverse society requires the development of a mindset which places medicine in a social, cultural, and historical context, alongside an active recognition and dedication to addressing societal problems. This mindset thrives in inclusive teaching environments and inclusive educators use experiences in the clinical environment to help their trainees develop their critical consciousness.

Suggested Strategies:
  • Actively develop the trainees’ cultural competence from their experiences in the clinical setting.

Campinha-Bacote (2002) proposes a model of cultural competence that includes knowledge of one’s own culture (cultural awareness), knowledge of other cultures (cultural knowledge), the ability to collect relevant cultural data regarding the patient’s presenting problem (cultural skill), and directly engaging in cross-cultural interactions with patients from culturally diverse backgrounds (cultural encounters). Clinical educators can encourage the development of these pillars of cultural competence by explicitly engaging trainees in a discussion about the cultural elements of each case, asking trainees what they learned, and pointing out important elements of cultural competence being demonstrated in the case. The U.S Department of Health and Human Services Office of Minority Health provides a useful review of concepts, policies and practices for teaching cultural competence 

  • Actively develop the trainees’ cultural humility from their experiences in the clinical setting.

Cultural competence is only one piece of this larger critical mindset. Cultural humility differs from cultural competence in that it emphasizes a life-long commitment to understanding and breaking down cultural barriers (Tervalon and Murray-Garcia, 1998; Campinha-Bacote, 2019). Questioning power imbalances and systemic inequity as part of each case builds this critical mindset and helps trainees identify the cognitive biases that could lead to diagnostic errors (Saposnik et al., 2016). Educators can also model an attitude of openness and egolessness by discussing their own areas for growth (Foronda et al., 2016; Hook et al., 2013; Isaacson, 2014).

Principle 4: Design experiences for accessibility.

Principle 4 of the Guide for Inclusive Teaching at Columbia recognizes that learners engage with course materials and demonstrate their learning in diverse ways. Inclusive teaching embraces this diversity by providing multiple ways for learners to engage and express their learning. Dr. Sheryl Burgstahler describes how Universal Design for Learning (UDL), a pedagogical approach grounded in learning sciences can benefit all learners, not just those with visible or formally accommodated disabilities. In the clinical environment, accommodating individual learners can be challenging, but incorporating UDL principles into the design of the clinical setting can create a more inclusive environment without relying on individual accommodations (Martyn et al., 2015).

Clinical Corollary 4.1 – Diversify approaches to teaching and engagement

UDL encourages educators to create flexible learning environments that allow trainees to access and engage with materials in a variety of ways. This flexibility ensures that no one type of learner is favored because all learners have the freedom to approach the learning experience in ways that are accessible and meaningful to them. These same core concepts are applicable to learning in clinical practice without sacrificing standards of competency and patient safety. 

Suggested Strategies:
  • Provide multiple ways for trainees to view and interact with the materials.

Diversifying the way content is presented benefits all trainees by giving them options for engaging with the material in their preferred ways. Educators can create flexibility by giving trainees access to both physical and electronic versions of materials and providing additional visual, audio, and text resources which illustrate ideas in multiple ways for trainees to study on their own. Educators can use technology and assistive applications, such as live scribe pens and mobile recording devices, in clinical settings to provide feedback and electronic note-taking during rounds (Morgan and Houghton, 2011).

Clinical Corollary 4.2 – Consider the inclusivity of clinical assessments.​

Teherani (2020) reports that the existing assessment processes vary in how well they capture achievement throughout the continuum of clinical training, tending to favor some kinds of skills (recall, oral presentations, rapid clinical judgment, and patient management) while undervaluing others (helpfulness, patient trust, rapport and patient communication). Bias in clinical assessment disadvantage trainees from identity groups historically excluded in healthcare professions (Hauer et al., 2019 ;Hauer et al., 2023) and can significantly impact a trainee’s future career choices (Teherani et al., 2018; Ross et al., 2018; Boatright et al., 2017). 

Suggested Strategies:
  • Provide multiple ways for trainees to demonstrate their knowledge.

Diversifying the types of assessments used in clinical settings avoids privileging some skills over others. High stakes, high stress assessments are more likely to privilege trainees from particular backgrounds over others. Using a combination of methods to create more frequent, lower stakes assessments allows trainees to demonstrate and be rewarded for a wider array of skills.

Principle 5: Reflect on one’s beliefs about teaching to maximize self-awareness and commitment to inclusion.

Principle 5 in the Guide to Inclusive Teaching at Columbia highlights the importance of self-reflection in mitigating the impacts of bias in the learning environment. Living in a society which contains systemic forms of oppression guarantees that everyone will internalize some form of bias. Educators must take care to not allow these biases to creep into the educational space and limit the success of trainees. Dr. Stephen Brookfield and Dr. Derald Wing Sue describe how these biases can manifest in instructional settings and the significance of critical self reflection for educators.

Clinical Corollary 5.1 – Examine your own identities, biases, and actions in the clinical setting.

Clinicians are no strangers to the concept of cognitive bias as it applies to a health professional’s clinical judgment. They know intimately that it can lead to potentially life-threatening diagnostic errors (Saposnik et al., 2016). Racial, gender, and cultural biases are another form of cognitive and affective bias and have the same capacity to influence decisions and to cause errors in judgment and behavior, (Brottman et al., 2020; Barbaria et al., 2012; Bullock et al., 2019) The same rigorous self-reflection that reduces cognitive bias in clinical decision making can be applied to an educators’ clinical teaching (Hauer et al., 2019; Plews-Ogan, et al., 2020).

Suggested Self-Reflection Questions:
  • What are my identities and how do others/my trainees perceive me?
  • What are my implicit (or explicit) biases?
  • Do I propagate, neutralize, or challenge stereotypes in my clinical practice? 
  • How do I handle challenging situations related to diversity, equity, and inclusion in healthcare?
  • How might the ways I work with patients and other health professionals promote inclusion or disinclusion?
  • How has my specific field of medicine contributed to forms of oppression and marginalization?

Resources and References

Inclusion at CUIMC

CTL Resources

The CTL is available to support you in this process. The CTL has designed a workshop to accompany this resource. The “Applying Inclusive Principles to Clinical Settings” workshop is available on request for any school, department, program or group of educators working with Columbia students. For more information visit the CTL’s Workshops to Go page. If you are looking for individual support you can email us at CTLFaculty@columbia.edu to schedule a 1-1 consultation. 

Here are some other CTL resources to help you on your inclusive teaching journey:

Additional Resources

MOOC Experts

  • Dr. Frank Tuitt – Vice President and Chief Diversity Officer at the University of Connecticut.
  • Dr. Michele DiPietro – Executive Director for educator Development, Recognition, and the Center for Excellence in Teaching and Learning and Professor of Data Science and Analytics at Kennesaw State University; Co-Author of the book “How Learning Works
  • Dr. Derald Wing Sue – Professor of Psychology and Education, Teachers College Columbia University
  • Dr. Brian Dewsbury– Associate Professor Biological Sciences, Florida International university; Principal Investigator, Science Education and Society Project
  • Dr. Stephen Brookfield – ​​Distinguished Scholar, Antioch University; Professor Emeritus, University of St. Thomas, Minneapolis-St. Paul
  • Dr. Sheryl Burgstahle– Director of Disabilities, Opportunities, Internetworking, and Technology Center, Director of Access Technology Center and Affiliate Professor of Education, University of Washington;

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