Bias - Foundations

Bias shapes how learners are seen, assessed, and supported. Explore how bias operates within individuals, between people, and through systems — and why shifting from intent to impact is essential for meaningful change.

What do we mean by bias?

Bias includes the unconscious, automatic associations and judgements that we make about others that influences our perceptions, interpretation, and decisions about them. Bias shapes how we see learners, how we teach, and how we evaluate trainees’ performances. Bias operates at multiple levels: 

  • Within ourselves through unconscious shortcuts and learned associations; 
  • Between us in our interactions and in the power dynamics at play in our contexts; and 
  • Around us in the structures, systems, and policies that reproduce inequities over time.  

Bias does not require intentional, explicit prejudice or discriminatory intent to have real consequences. Its effects emerge through routine practices and everyday judgments, especially in settings characterized by time pressures, uncertainty, and high stakes.These patterns are not random. They develop through:

  • Repeated exposure to cultural narratives;
  • Professional norms and institutional traditions;
  • Personal experiences;
  • Media representations; and
  • Historical power structures.

Bias helps us manage complexity. In busy clinical environments, cognitive shortcuts allow us to make rapid decisions. The problem is not that we use shortcuts. The problem is that shortcuts are shaped by unequal social patterns.

Bias is, therefore, not a personal defect. It is a predictable feature of human cognition operating within social systems.

Why does bias matter in health professions education (HPE)?

HPE relies heavily on interpretation and judgment. For example, educators decide who is progressing well, who is ready for more responsibility, and who may need additional support. These decisions influence learners’ confidence, opportunities, and long-term career paths.

Because assessment involves interpretation rather than purely objective measurement, it is shaped by expectations, about communication, leadership, professionalism, and competence. Even small differences in how feedback is framed or how performance is interpreted can have a accumulative effect over time.

Bias also shapes everyday interactions in clinical learning environments. Who is encouraged to speak? Who is given the benefit of the doubt? Who receives detailed coaching versus brief corrective comments? These interactions contribute to learners’ sense of belonging and safety.

The implications extend beyond education. Training environments shape how future clinicians reason, communicate, and collaborate. In this sense, attention to bias is connected to fairness for learners as well as to educational quality and patient care.

How does bias operate at different levels?

Bias can be understood as operating at several interconnected levels.

  • At the individual level, bias reflects cognitive tendencies. Under time pressure or uncertainty, we rely more heavily on heuristics. These may influence how we interpret hesitation, confidence, or communication style.
  • At the interpersonal level, bias appears in patterns of interaction. It may shape who is interrupted, who receives advocacy in high-stakes discussions, or whose errors are framed as learning opportunities. These patterns are often subtle and become visible only when examined collectively.
  • At the structural level, bias can be embedded in tools, policies, and norms. Assessment forms, definitions of professionalism, and promotion processes may privilege certain behaviors or communication styles. These structures often appear neutral but may produce uneven outcomes.

Looking across these levels allows us to consider both personal reflection and system design as part of the conversation.

Is bias inevitable?

Bias is a natural feature of human cognition, institutions are built within social histories that are not neutral. Therefore, bias is difficult to eliminate entirely.

At the same time, its impact is not fixed. Structured processes, transparent criteria, diverse decision-making groups, and careful review of outcome patterns can reduce the influence of bias. Awareness alone is rarely sufficient, but it can be a starting point for more deliberate design.

Rather than aiming for perfection, the goal should be to build educational systems that are reflective and responsive — i.e., capable of noticing patterns of bias and adjusting accordingly.

Framing bias as a matter of educational quality and continuous improvement may help move the conversation beyond blame and toward shared responsibility.

Further reading

Explores why awareness-based approaches to bias are insufficient and proposes moving toward longitudinal, system-oriented change.

Synthesizes evidence on how implicit bias affects clinical care and education, highlighting gaps between recognition and outcomes.

Introduces a framework for understanding how social, political, and institutional structures shape clinical and educational interactions.

  • Monteiro, S., Acai, A., Kahlke, R., Chan, T. M., & Sukhera, J. (2024). Shifting paradigms: A collective and structural strategy for addressing healthcare inequity. Journal of Evaluation in Clinical Practice, 30(6), 887–893. https://doi.org/10.1111/jep.14013

Argues for moving beyond individual debiasing toward collective responsibility, leadership, and structural redesign.

  • Teherani, A., Perez, S., Muller-Juge, V., Lupton, K., & Hauer, K. E. (2020). A Narrative Study of Equity in Clinical Assessment Through the Antideficit Lens. Academic Medicine, 95(12S), S121–S130. https://doi.org/10.1097/ACM.0000000000003690

Centers learner perspectives to show how assessment practices can either reproduce deficit narratives or recognize achievement more equitably.