AAIM Recommendations to Promote Equity in the Clerkship Clinical Learning Environment

Abstract

Perspectives Viewpoints•Successful approaches to address inequities in the clerkship clinical learning environment (CCLE) are unclear.•Clerkship and medical education leaders have the opportunity to collaborate to promote equity in the CCLE.•Recommended strategies include acknowledging imposter syndrome, fostering a growth mindset, cultivating psychological safety, recognizing implicit bias and addressing mistreatment, designing curricula to promote inclusion, promoting use of certified interpreters, intentional recruitment for faculty educational opportunities, and educational continuous quality improvement.IntroductionDespite widespread recognition of inequities related to sex, race, and ethnicity in undergraduate medical education, effective solutions have been difficult to identify. In this perspective, the Alliance for Academic Internal Medicine (AAIM) focuses on issues specific to the clerkship clinical learning environment (CCLE).The pre-clerkship classroom tends to be closely regulated, with standards provided by leadership and understood by teachers and learners. In contrast, the CCLE is more variable, with multiple clinical, structural, systems-based, and educational factors that may introduce or amplify inequities in learner experiences.Adapted from the definition of health equity, educational equity describes the concept that all learners have the opportunity to attain their full potential without structural or social barriers.1National Academies of Sciences, Engineering, and MedicineCommunities in Action: Pathways to Health Equity. The National Academies Press, Washington, DC2017https://doi.org/10.17226/24624Crossref Scopus (168) Google Scholar Educational equity in the CCLE depends on clerkship and other medical education leaders sharing a mental model of the CCLE scope. These recommendations are based on a conceptual framework for the clinical learning and working environment (LWE) AAIM developed in 2017.2Jaffe RC Bergin CR Loo LK et al.Nested domains: a global conceptual model for optimizing the clinical learning environment.Am J Med. 2019; 132: 886-891Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar While these recommendations come from the perspective of clerkship leaders, the Alliance recognizes that inequities in the CCLE are not isolated to clerkships and therefore, recommends that clerkship and other medical education leaders collaborate to develop and implement interventions.AAIM Conceptual Model to Optimize the Learning EnvironmentIn 2017, AAIM created a conceptual model to describe the LWE.2Jaffe RC Bergin CR Loo LK et al.Nested domains: a global conceptual model for optimizing the clinical learning environment.Am J Med. 2019; 132: 886-891Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar This model describes 4 factors that interact dynamically: interconnectedness of all domains in the medical education continuum, learners at multiple stages, central role of the patient, and sociocultural context. The model also describes 4 domains through which educators can view the LWE: personal, relational, curricular, and structural. These domains can be used to categorize factors that impact the learning environment when analyzing and planning innovations. The recommendations to promote educational equity in the CCLE are organized by these domains (Table).2Jaffe RC Bergin CR Loo LK et al.Nested domains: a global conceptual model for optimizing the clinical learning environment.Am J Med. 2019; 132: 886-891Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarTableRecommendations to Promote Equity in the Clerkship Clinical Learning Environment (CCLE) Using the AAIM Conceptual ModelAAIM Conceptual Model Domain and DefinitionSuggested TopicsRecommendations for Clerkship and Medical Education Leaders: Clerkship and Other Medical Education Leaders Should Collaborate to Develop and Implement Action Plans, as Inequities in the CCLE are Not Isolated to Core ClerkshipsFeasibility (High, Moderate, Low) of Implementation Led by Clerkship Director*High feasibility: Multiple resources already exist and can be readily adapted, that is, Clerkship Directors can implement on their own, with minimal need to develop new content; Low feasibility: Fewer resources exist and may require more content development with external groups, for example, central medical school or hospital system leadership, content experts.PersonalImposter syndrome and stereotype threat•Educate students and faculty/resident supervisors about imposter syndrome and stereotype threat and their impact on learners’ experiences•Encourage faculty/resident supervisors to share their experiences with imposter syndrome or stereotype threat and share helpful strategies.ModerateThe lens through which a learner experiences the CCLE and the intrinsic qualities the learner adds.Growth mindset•Encourage students to self-identify learning goals and participate in creating their own learning action plans.•Educate faculty/resident supervisors in self-theories and how to foster a growth mindset.Low to ModerateRelationalPsychological safety•Provide faculty and residents with resources and support to help them develop the skills to cultivate a climate of psychological safety in the CCLE.•Incorporate techniques such as inviting input from all team members, active listening, debriefing, engaging in effective feedback to engender trust and build alliances.Low to ModerateThe ways in which individuals or groups interact and the impact of these interactions upon learners and the CCLE as a system.Implicit bias and mistreatment•Incorporate implicit bias recognition and management training in faculty and resident development programs.•Educate teams on how to recognize and address all forms of mistreatment.Low to ModerateCurricularCultural humility, inclusivity, and belonging•Include DEI in the curriculum objectives.•Be intentional with the use of race, gender and sexual identity in teaching cases and materials.•Do not use race routinely in the HPI. If race or ancestry is relevant to the case, it may be discussed in the social history, or in family history.•Teach how to ask about an individual's self-identified racial, ethnic, gender and sexual identities, preferred language, and accommodations used or needed.•Teach and model use of preferred name, pronunciation, and pronouns in classroom and clinical settings.•Acknowledge the current controversies in race-based medicine practice such as the use of race in clinical algorithms and study interpretation.HighFactors relating to formal and educational experiences, and includes a process of learner assessment and feedback. Hidden curriculum is part of this domain, although this overlaps with other domains.StructuralUse of certified interpreters•Recommend teams work with assigned certified interpreters. Discourage using students as ad-hoc interpreters.•Allow certified student interpreters to volunteer to interpret for team patients (opt-in approach).•Encourage all students to work with patients with limited English proficiency and to utilize interpretive services.HighThe organizational, programmatic, and physical context within which clinical learning occurs. Components can be specific to the local CCLE, or may be externally defined.Faculty educational opportunities: Mitigating the effect of “minority tax” and “affinity bias”•Create a “request for application” (RFA) process for all clerkship teaching and mentoring opportunities. The RFA should include a description of the opportunity and selection criteria and should be disseminated widely within relevant settings.•Be deliberate in recruitment and hiring efforts and intentionally include UIM faculty as educators for all clerkship topics, not exclusively DEI topics.HighEducational continuous quality improvement•Regularly review school-collected data that relates to the CCLE and equity and inclusion, as part of the annual clerkship review.•Seek out additional verbal feedback from students through non-evaluating staff or faculty, as formal course evaluations may not capture inequitable learning experiences.•Build centrally-supported, anonymous reporting mechanisms to gather student reports about the CCLE and mistreatment.Moderate to HighAdapted from Table 2 of Jaffe et al, 2019.2AAIM = Alliance for Academic Internal Medicine; DEI = diversity, equity, and inclusion; HPI = history of present illness; UIM = underrepresented in medicine. High feasibility: Multiple resources already exist and can be readily adapted, that is, Clerkship Directors can implement on their own, with minimal need to develop new content; Low feasibility: Fewer resources exist and may require more content development with external groups, for example, central medical school or hospital system leadership, content experts. Open table in a new tab PersonalAcknowledging Imposter Syndrome and Stereotype ThreatImposter syndrome is the syndrome of persistent self-doubt despite personal accomplishment. Prevalent in medical professionals, it has been demonstrated to be higher in women and groups historically underrepresented in medicine (UIM).3Bravata DM Watts SA Keefer AL et al.Prevalence, predictors, and treatment of impostor syndrome: a systematic review.J Gen Intern Med. 2020; 35: 1252-1275Crossref PubMed Scopus (88) Google Scholar It has been associated with lower job performance, lower job satisfaction, and higher burnout.4Villwock JA Sobin LB Koester LA Harris TM Impostor syndrome and burnout among American medical students: a pilot study.Int J Med Educ. 2016; 7: 364-369Crossref PubMed Scopus (125) Google Scholar Stereotype threat describes when an individual's concern for confirming negative stereotypes about their identity group leads to underperformance in a given domain.5Bullock JL Lockspeiser T Del Pino-Jones A Richards R Teherani A Hauer KE They don't see a lot of people my color: a mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships.Acad Med. 2020; 95 (11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations): S58-S66Crossref PubMed Scopus (29) Google Scholar As students transition among clerkships, teams, and systems, they may acutely experience both phenomena, which may then diminish their sense of belonging and affect their ability to perform well in the CCLE. Systemic factors such as a lack of diverse role models may amplify these feelings. Familiarity with these concepts is therefore important for learners and their faculty/resident supervisors.Recommendations•Educate students and faculty/resident supervisors about imposter syndrome and stereotype threat and their impact on learner experiences. This content6Rivera N Feldman EA Augustin DA Caceres W Gans HA Blankenburg R Do I belong here? Confronting imposter syndrome at an individual, peer, and institutional level in health professionals.MedEdPORTAL. 2021; 17: 11166Crossref PubMed Scopus (4) Google Scholar,7Bindman J, Connor D, Wheeler M. UCSF School of Medicine DEI Tips Sheet for the Clinical Learning Environment, Version 2.0. Developed by Academy of Medical Educators DEI Committee based on member expertise @ 2019 AME Meetings and updated 1/2022. Available at: https://ucsf.app.box.com/s/gv6wn3cqnmdhlouhyw5ul7dk3k6zkp1d. Accessed March 29, 2022.Google Scholar can be introduced during the pre-clerkship curriculum and in the clerkship curriculum with students and supervisors.•Encourage faculty/resident supervisors to share their experiences with imposter syndrome or stereotype threat and share helpful strategies.Fostering a Growth MindsetWhen individuals hold a growth mindset, they believe that abilities can improve through challenge and learning from failure.8Dweck CS Self-theories: Their Role in Motivation, Personality, and Development. Taylor & Francis, New York2013Crossref Google Scholar Alternatively, when individuals hold a fixed mindset, they believe that characteristics such as talent are immutable. Attending to a growth mindset and mastery orientation in the CCLE may cultivate an environment that allows students to meet their full potential.9Canning EA Muenks K Green DJ Murphy MC STEM faculty who believe ability is fixed have larger racial achievement gaps and inspire less student motivation in their classes.Sci Adv. 2019; 5: eaau4734Crossref PubMed Scopus (152) Google Scholar, 10Theard MA Marr MC Harrison R The growth mindset for changing medical education culture.EClinicalMedicine. 2021; 37100972Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 11Richardson D Kinnear B Hauer KE et al.Growth mindset in competency-based medical education.Med Teach. 2021; 43: 751-757Crossref PubMed Scopus (9) Google ScholarRecommendations•Encourage students to self-identify learning goals and participate in creating their own learning action plans.•Train faculty/resident supervisors in self-theories10Theard MA Marr MC Harrison R The growth mindset for changing medical education culture.EClinicalMedicine. 2021; 37100972Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and how to foster a growth mindset.RelationalCultivating Psychological SafetyPsychological safety describes a person's perceptions of the consequences of taking interpersonal risks in a particular context, such as a workplace, and is a critical factor in teamwork and team learning.12Edmondson AC Zhike L Psychological safety: the history, renaissance, and future of an interpersonal construct.Annu Rev Organ Psychol Organ Behav. 2014; 1: 23-43Crossref Scopus (688) Google Scholar Tsuei et al13Tsuei SH Lee D Ho C Regehr G Nimmon L. Exploring the construct of psychological safety in medical education.Acad Med. 2019; 94 (11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 58th Annual Research in Medical Education Sessions): S28-S35Crossref PubMed Scopus (48) Google Scholar describe psychological safety in medical education as the “state of feeling freed from a sense of judgment by others such that learners can authentically and wholeheartedly concentrate on engaging with a learning task without a perceived need to self-monitor their projected image.” When faculty/resident supervisors foster psychological safety, they strengthen team dynamics, allowing students to feel safe to explore difficult topics, take risks, and acknowledge their limits.13Tsuei SH Lee D Ho C Regehr G Nimmon L. Exploring the construct of psychological safety in medical education.Acad Med. 2019; 94 (11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 58th Annual Research in Medical Education Sessions): S28-S35Crossref PubMed Scopus (48) Google Scholar,14Torralba KD Jose D Byrne Psychological safety, the hidden curriculum, and ambiguity in medicine.Clin Rheumatol. 2020; 39: 667-671Crossref PubMed Scopus (21) Google ScholarRecommendations•Provide faculty and residents with resources15Agency for Healthcare Research and Quality. Creating psychological safety in teams: handout. 2018. Available at: https://www.ahrq.gov/evidencenow/tools/psychological-safety.html. Accessed January 20, 2022.Google Scholar and support to help them develop the skills to cultivate a climate of psychological safety in the CCLE.•Incorporate techniques such as inviting input from all team members, active listening, debriefing, recognizing the limits of one's own knowledge, and engaging in effective feedback to engender trust and build alliances.14Torralba KD Jose D Byrne Psychological safety, the hidden curriculum, and ambiguity in medicine.Clin Rheumatol. 2020; 39: 667-671Crossref PubMed Scopus (21) Google Scholar,15Agency for Healthcare Research and Quality. Creating psychological safety in teams: handout. 2018. Available at: https://www.ahrq.gov/evidencenow/tools/psychological-safety.html. Accessed January 20, 2022.Google Scholar Examples of phrases15Agency for Healthcare Research and Quality. Creating psychological safety in teams: handout. 2018. Available at: https://www.ahrq.gov/evidencenow/tools/psychological-safety.html. Accessed January 20, 2022.Google Scholar that can be used in either team settings or one-on-one situations include:○“If you see anything that concerns you, please speak up. We're a team focused on being the best we can be for our patients and for each other, and we have to have each other's backs.”○“Great point! The whole team should hear that. Can you bring it up on rounds tomorrow?”○“I'm not sure we're following the guideline correctly. Let's check together.”Recognizing Implicit Bias and Addressing MistreatmentImplicit bias refers to attitudes or stereotypes that unconsciously affect our understanding, actions, and decisions. They can be difficult to recognize, acknowledge, and manage, and can have negative consequences on the CCLE, learners and faculty, clinical decision-making, and quality of care.16Greenwald AG Banaji MR The implicit revolution: reconceiving the relation between conscious and unconscious.Am Psychol. 2017; 72: 861-871Crossref PubMed Scopus (99) Google Scholar,17Backhus LM Lui NS Cooke DT Bush EL Enumah Z Higgins R Unconscious bias: addressing the hidden impact on surgical education.Thorac Surg Clin. 2019; 29: 259-267Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar When faculty and learners confront their own biases18Sukhera J Watling C A framework for integrating implicit bias recognition into health professions education.Acad Med. 2018; 93: 35-40Crossref PubMed Scopus (82) Google Scholar and understand the sociocultural context for their biases, they can foster mutual understanding and respect, as well as unlearn stereotypes.19Boscardin CK Reducing implicit bias through curricular interventions.J Gen Intern Med. 2015; 30: 1726-1728Crossref PubMed Scopus (21) Google ScholarMistreatment encompasses microaggressions (the subtle, intentional or unintentional, insults or behaviors against a member of a historically marginalized group) and macroaggressions (the overt aggressions and discrimination against a member of a historically marginalized group).20Sue DW Capodilupo CM Torino GC et al.Racial microaggressions in everyday life: implications for clinical practice.Am Psychol. 2007; 62: 271-286Crossref PubMed Scopus (2513) Google Scholar Microaggressions in the CCLE can cause psychological distress, depression, and anxiety21Torres L Driscoll MW Burrow AL Racial microaggressions and psychological functioning among highly achieving African-Americans: a mixed-methods approach.J Soc Clin Psychol. 2010; 29: 1074-1099Crossref Scopus (183) Google Scholar by, for example, triggering stereotype threat and increased cognitive load.5Bullock JL Lockspeiser T Del Pino-Jones A Richards R Teherani A Hauer KE They don't see a lot of people my color: a mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships.Acad Med. 2020; 95 (11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations): S58-S66Crossref PubMed Scopus (29) Google Scholar Mistreatment from patients also affects emotional well-being and detracts from the CCLE.22Wheeler M de Bourmont S Paul-Emile K et al.Physician and trainee experiences with patient bias.JAMA Intern Med. 2019; 179: 1678-1685Crossref PubMed Scopus (44) Google Scholar Students have described uncertainty about how to respond to these encounters.22Wheeler M de Bourmont S Paul-Emile K et al.Physician and trainee experiences with patient bias.JAMA Intern Med. 2019; 179: 1678-1685Crossref PubMed Scopus (44) Google ScholarRecommendations•Incorporate implicit bias recognition and management training in faculty and resident development programs.○Key features include creating a safe learning context; increasing knowledge about the science of implicit bias; emphasizing how implicit bias influences behaviors and patient outcomes; increasing self-awareness of existing biases; improving conscious efforts to overcome implicit bias; and enhancing awareness of how bias influences others.18Sukhera J Watling C A framework for integrating implicit bias recognition into health professions education.Acad Med. 2018; 93: 35-40Crossref PubMed Scopus (82) Google Scholar,23Gonzalez CM Walker SA Rodriguez N Noah YS Marantz PR Implicit bias recognition and management in interpersonal encounters and the learning environment: a skills-based curriculum for medical students.MedEdPORTAL. 2021; 17: 11168Crossref PubMed Scopus (3) Google Scholar○Educate teams on how to recognize and address all forms of mistreatment. Consider preemptively asking students their preferences in how to manage situations of mistreatment, including individual or team debriefs and support for the student, or no debriefs.24Bullock JL O'Brien MT Minhas PK Fernandez A Lupton KL Hauer KE No one size fits all: a qualitative study of clerkship medical students' perceptions of ideal supervisor responses to microaggressions.Acad Med. 2021; 96: S71-S80Crossref PubMed Scopus (1) Google Scholar,25Sotto-Santiago S Mac J Duncan F Smith J “I didn’t know what to say”: responding to racism, discrimination, and microaggressions with the OWTFD approach.MedEdPORTAL. 2020; 16: 10971Crossref PubMed Scopus (17) Google Scholar This approach promotes psychological safety and empowers the student.24Bullock JL O'Brien MT Minhas PK Fernandez A Lupton KL Hauer KE No one size fits all: a qualitative study of clerkship medical students' perceptions of ideal supervisor responses to microaggressions.Acad Med. 2021; 96: S71-S80Crossref PubMed Scopus (1) Google Scholar Include this information in team orientation e-mails for wide dissemination and review it at annual resident and faculty meetings.CurricularCultural Humility, Inclusivity, and BelongingAlthough educators have long used cultural competency as a framework for education about race, culture, and social determinants of health, there is growing recognition that this framework may have the unintended consequence of propagating stereotypes.26Acquaviva KD Mintz M Perspective: are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations.Acad Med. 2010; 85: 702-705Crossref PubMed Scopus (34) Google Scholar Educators are therefore reframing the competency as cultural humility, reflecting a more self-aware and inclusive perspective. A review of clerkship teaching cases identified 6 common mistakes faculty make when using race and culture in teaching materials.27Krishnan A Rabinowitz M Ziminsky A Scott SM Chretien KC Addressing race, culture, and structural inequality in medical education: a guide for revising teaching cases.Acad Med. 2019; 94: 550-555Crossref PubMed Scopus (41) Google Scholar They include using race as a genetic risk factor without acknowledging the social and structural causes of disparities; associating disease with individual behaviors without providing the context of social and structural factors; describing patients using reductionist and essentialist portrayals of non-Western cultures and people of color; ignoring or portraying a sense of futility in addressing social and structural causes of disease and illness; developing cases that lack critical reflection on health disparities and implicit bias; and not portraying minority identities among faculty, students, and patients that accurately reflect the current US population.27Krishnan A Rabinowitz M Ziminsky A Scott SM Chretien KC Addressing race, culture, and structural inequality in medical education: a guide for revising teaching cases.Acad Med. 2019; 94: 550-555Crossref PubMed Scopus (41) Google Scholar Inclusion of education on gender, sex, and sexuality is also critical for promoting equity in medical education.28Gay and Lesbian Medical Association (GLMA)Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. Gay and Lesbian Medical Association, San Francisco, CA2006https://www.glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdfGoogle ScholarRecommendations•Include diversity, equity, and inclusion (DEI) in clerkship curricular objectives. For example, include the Association of American Medical Colleges core Entrustable Professional Activity 5.5: “Demonstrates sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.”29Aiyer M, Garber A, Ownby A, Trimble G. Core Entrustable Professional Activities for Entering Residency — EPA 5.5. Obeso V, Brown D, Phillipi C, eds. Washington, DC: Association of American Medical Colleges; 2017. Available at: https://aamc.org/initiatives/coreepas/publicationsandpresentations. Accessed May 17 2022.Google Scholar•Be intentional with the use of race, gender, and sexual identity in teaching cases and materials. Several evidence-based resources exist to guide this process.27Krishnan A Rabinowitz M Ziminsky A Scott SM Chretien KC Addressing race, culture, and structural inequality in medical education: a guide for revising teaching cases.Acad Med. 2019; 94: 550-555Crossref PubMed Scopus (41) Google Scholar,30Dogra N Reitmanova S Carter-Pokras O Twelve tips for teaching diversity and embedding it in the medical curriculum.Med Teach. 2009; 31: 990-993Crossref PubMed Scopus (50) Google Scholar To identify potential bias when reviewing/writing a case, ask 3 things: does the case involve a patient of color or minority culture; is attribution of a patient's health belief or practice made to cultural values, beliefs, or practices; and is guidance provided on how to approach minority patients (based on their “unique belief systems” as a group)? If the answer is yes, consider editing to mitigate bias.•Do not use race routinely in the history of present illness. If race or ancestry is relevant to the case, it may be discussed in the social history or in family history.31Amutah C Greenidge K Mante A et al.Misrepresenting race – the role of medical schools in propagating physician bias.N Engl J Med. 2021; 384: 872-878Crossref PubMed Scopus (79) Google Scholar,32Olufadeji A Dubosh NM Landry A Guidelines on the use of race as patient identifiers in clinical presentations.J Natl Med Assoc. 2021; 113: 428-430PubMed Google Scholar•Teach how to ask about an individual's self-identified racial, ethnic, gender, and sexual identities,33Potter LA Burnett-Bowie SM Potter J Teaching medical students how to ask patients questions about identity, intersectionality, and resilience.MedEdPORTAL. 2016; 12: 10422Crossref PubMed Google Scholar preferred language, and accommodations used or needed.•Teach and role model use of preferred name, pronunciation, and pronouns in orientation, classroom, and clinical settings.28Gay and Lesbian Medical Association (GLMA)Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. Gay and Lesbian Medical Association, San Francisco, CA2006https://www.glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdfGoogle Scholar•Acknowledge the current controversies in race-based medicine practice such as the use of race in clinical algorithms (atherosclerotic cardiovascular disease risk) and study interpretation (kidney function and pulmonary function tests).34Vyas DA Eisenstein LG Jones DS Hidden in plain sight – reconsidering the use of race correction in clinical algorithms.N Engl J Med. 2020; 383: 874-882Crossref PubMed Scopus (447) Google Scholar For example, state that there is a widespread current discussion about race-based medical practice, and that it is important and it is evolving.35Cerdeña JP Plaisime MV Tsai J From race-based to race-conscious medicine: how anti-racist uprisings call us to act.Lancet. 2020; 396: 1125-1128Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar•Contextualize group differences in disease/illness burden by identifying social determinants of health and racism rather than race as risk factors for illness.31Amutah C Greenidge K Mante A et al.Misrepresenting race – the role of medical schools in propagating physician bias.N Engl J Med. 2021; 384: 872-878Crossref PubMed Scopus (79) Google Scholar,36Paradies Y Ben J Denson N et al.Racism as a determinant of health: a systematic review and meta-analysis.PLoS One. 2015; 10e0138511Crossref PubMed Scopus (962) Google ScholarStructuralUse of Certified InterpretersProfessional interpreters have been shown to improve the care for patients with limited English proficiency (LEP) in the areas of communication (errors and comprehension), utilization (shorter length of stay and lower readmission rates), clinical outcomes, and satisfaction.37Karliner LS Jacobs EA Chen AH Mutha S Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature.Health Serv Res. 2007; 42: 727-754Crossref PubMed Scopus (817) Google Scholar,38Lindholm M Hargraves JL Ferguson WJ Reed G Professional language interpretation and inpatient length of stay and readmission rates.J Gen Intern Med. 2012; 27: 1294-1299Crossref PubMed Scopus (135) Google Scholar Professional interpretation services are required by law at any institution receiving federal funding (Title VI of the Civil Right Act and the Executive Order 13166).39Chen AH Youdelman MK Brooks J The legal framework for language access in healthcare settings: Title VI and beyond.J Gen Intern Med. 2007;; 22: 362-367Crossref Scopus (157) Google ScholarStudents who speak a second language may be asked to interpret for patients with LEP even when not fluent or certified.40Vela MB Fritz CF Press VG Girotti JG Medical students' experiences and perspectives on interpreting for LEP patients at two U.S. medical schools.J Racial Ethn Health Disparities. 2016; 3: 245-249Cr