Recommendations to Promote Equity in the Clerkship CLE

Introduction

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 (1 Reference). Educational equity in the CCLE depends on clerkship and other medical education leaders sharing a mental model of the CCLE scope. We base our recommendations on a conceptual framework for the clinical learning and working environment (LWE) presented by AAIM (2 Reference). We offer these recommendations from the perspective of clerkship leaders, however we recognize that inequities in the CCLE are not isolated to clerkships. We therefore recommend that clerkship and other medical education leaders collaborate to develop and implement interventions.  

AAIM Conceptual Model to Optimize the Learning Environment

In 2017 an AAIM collaborative created a conceptual model to describe the LWE (2 Reference). This model describes four 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 four 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. We organize our recommendations to promote educational equity in the CCLE using these domains (Table 1).

Personal

Acknowledging Imposter Syndrome and Stereotype Threat

Background: Imposter 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).(3) It has been associated with lower job performance, lower job satisfaction and higher burnout.(4) Stereotype threat describes when an individual’s concern for confirming negative stereotypes about their identity group leads to underperformance in a given domain.(5) As students transition between 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 learners’ experiences. This can be introduced during the pre-clerkship curriculum and in the clerkship curriculum with students and supervisors.
  • Resource: MedEdPortal curriculum on imposter syndrome (6 Reference)
  • Resource: Example tip sheet on topics, such as imposter syndrome and stereotype threat, to consider when leading a team orientation at the beginning of a clinical rotation (7 Reference)
• Encourage faculty/resident supervisors to share their experiences with imposter syndrome and/or stereotype threat and share helpful strategies.

Fostering a Growth Mindset

Background: When individuals hold a growth mindset, they believe that abilities can improve through challenge and learning from failure.(8) 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.(9-11)

Recommendations:

• Encourage students to self-identify learning goals and participate in creating their own learning action plans.
• Train faculty/resident supervisors in self-theories and how to foster a growth mindset.
  • Resource: Theard et al. Figure: Racism to Anti-Racism using a Growth Mindset Framework (10 Reference)
  • Resource: Example presentation on growth mindset (Appendix 1)

Relational

Cultivating Psychological Safety

Background: Psychological 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. (12) Tsuei et al. (2019) 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.” (13) 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. (13,14)

Recommendations:

• Provide faculty and residents with resources and support to help them develop the skills to cultivate a climate of psychological safety in the CCLE.
  • Resource: AHRQ Creating Psychological Safety in Teams (15 Reference)

• 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. (14,15)
  • Examples of phrases that can be used in either team settings or one-on-one situations: (15)
    • “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 Mistreatment

Background: Implicit 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. (16,17) When faculty and learners confront their own biases (18) and understand the sociocultural context for their biases, they can foster mutual understanding, respect and unlearn stereotypes. (19)

Mistreatment 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). (20) Microaggressions in the CCLE can cause psychological distress, depression and anxiety (21) by triggering stereotype threat and increased cognitive load, for example.5 Mistreatment from patients also affects emotional well-being and detracts from the CCLE. (22) Students have described uncertainty around how to respond to these encounters. (22)

Recommendations:

• Incorporate implicit bias recognition and management training in faculty and resident development programs.
  • Key features: 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. (1)(8)
  • Resource: Implicit Association Test. https://implicit.harvard.edu/implicit/takeatest.html

• Resource: MedEdPortal curriculum on responding to implicit bias (23 Reference)

• Educate teams on how to recognize and address all forms of mistreatment
  • Preemptively ask all students their preferences in how to manage situations, including individual or team debriefs and support for the student, or no debriefs. (24) This approach promotes psychological safety and empowers the student. (24) Include this information in team orientation emails for wide dissemination and review it at annual resident and faculty meetings
  • Resource: Bullock et al. Figure 1: Bystander microaggression intervention guide (24 Reference)

• Resource: MedEdPortal curriculum on responding to mistreatment (25 Reference)

Curricular

Cultural humility, inclusivity, and belonging

Background: Although educators have long used cultural competency as a framework for education regarding race, culture, and social determinants of health, there is growing recognition that this framework may have the unintended consequence of propagating stereotypes. (26) Educators are therefore reframing the competency as cultural humility, reflecting a more self-aware and inclusive perspective. A review of clerkship teaching cases by Krishnan et al. (2019) identified six common mistakes faculty make when using race and culture in teaching materials. (27) 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 U.S population. (27) Inclusion of education on gender, sex, and sexuality is also critical for promoting equity in medical education. (28) 

Recommendations:

• Include diversity, equity and inclusion (DEI) in clerkship curricular objectives.
  • For example, include the Association of American Medical Colleges (AAMC) core Entrustable Professional Activity (EPA) 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”. (29)
• 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. (27,30)
  • Resource: A Race and Culture Guide for Editors of Teaching cases supplemental digital appendix: (27 Reference)
  • To identify potential bias when reviewing/writing a case, ask three things: 1) Does the case involve a patient of color and/or minority culture? (2) Is attribution of a patient’s health belief or practice made to cultural values, beliefs or practices? and (3) 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. (31,32)
  • Resource: Guidelines on the use of race as patient identifiers in clinical presentations. (32)
• Teach how to ask about a person’s self-identified racial, ethnic, gender and sexual identities, preferred language, and accommodations used or needed.
  • Resource: MedEdPortal Curriculum on how to ask patients questions about identity (33 Reference)
• Teach and role model use of preferred name, pronunciation, and pronouns in classroom and clinical settings. (28)
  • Resource: a helpful website that provides a review for those unfamiliar with the use of pronouns https://www.mypronouns.org/
  • Include pronouns in orientation introductions.
• Acknowledge the current controversies in race-based medicine practice such as the use of race in clinical algorithms (ASCVD risk) and study interpretation (kidney function and pulmonary function tests). (34)
  • For example, state that there is a widespread current discussion about race-based medical practice, and that it is important and it is evolving. (3) (5)
• Contextualize group differences in disease/illness burden by identifying social determinants of health and racism rather than race as risk factors for illness. (31,3) (6)

Structural

Use of certified interpreters

Background: Professional 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. (37,38) 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). (39)

Students who speak a second language may be asked to interpret for patients with LEP even when not fluent or certified. (40) Use of ad-hoc interpreters has been demonstrated to compromise patient safety and patient care. (41) While interpreting can be an opportunity for students to contribute to patient care, it can detract from their role as a learner. Maintaining a distinction between their clinical and interpreter roles can be challenging and can introduce inequities. (42)

Recommendations:

• Recommend teams work with certified interpreters. Discourage using students as ad-hoc interpreters.
  • Add this information to team orientation emails for wide dissemination to students and supervising physicians.
• Allow certified student interpreters to volunteer to interpret for team patients (opt-in approach). Supervisors should not ask students to interpret for multiple patients as this may detract from their role as a learner.
• Encourage all students to work with patients with LEP and to utilize interpretive services.
  • Resource: Example handout on use of certified interpreters (Appendix 2)

Faculty educational opportunities: Mitigating the effect of “minority tax” and “affinity bias”

Background: Faculty from UIM groups are often asked to take on extra responsibilities in medical education, e.g., mentoring UIM learners or teaching DEI-related concepts. While many UIM faculty may take pride in contributing to DEI efforts, they are often not compensated or given time to support their efforts. This has been described as a “minority tax”. (43) 

Educational leaders may be prone to “affinity bias,” the unconscious favoring of faculty with shared connections or backgrounds. (44 )This bias may cause leaders to preferentially offer educational opportunities and possible career advancement to certain faculty members.

Recommendations:

• Create a “request for application” (RFA) process for all clerkship teaching and mentoring opportunities. This request 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.

Educational Continuous Quality Improvement

Background: Adopting a culture of quality improvement (QI) means shifting focus from individual blame to system responsibility. (45 )The educational continuous QI  (ECQI) process includes monitoring programmatic variables related to identity to evaluate for differences between groups, and a review of mistreatment reports submitted by students to assess for bias-related events and opportunity for action. (46-48) It is critical to adopt an approach of system responsibility to support psychological safety and encourage growth mindset in supervisors.

Recommendations:

• Build anonymous reporting mechanisms to gather student reports about the CCLE and mistreatment. This can include an automated process that reviews anonymous course evaluation comments for reports of bias. (48,49)
• Review school-collected quantitative and qualitative data on variables that relate to the CCLE and equity and inclusion, as part of the annual clerkship review process (e.g., metrics that could be related to an inequitable learning environment). Utilize QI techniques to address data systematically.
  • Metrics could include differences in numerical performance and grades by certain demographics.
  • Other data can include the number and type of mistreatment experiences reported by students, and a review of student satisfaction with the clerkship to identify areas of concern.
• Seek out additional verbal feedback from students through non-evaluating staff or faculty, as formal course evaluations may not capture inequitable learning experiences.

Conclusion

We describe evidence-based recommendations to address inequities in the CCLE using AAIM’s conceptual model as a framework. We believe that clerkship leaders and other medical education leaders can partner together to address and implement strategies to promote equity in the CCLE.

References

1. National Academies of Sciences, Engineering, and Medicine. Communities in Action: Pathways to Health Equity. 2017. (available at)  https://doi.org/10.17226/24624. Accessed on January 21 2022.
2. Jaffe RC, Bergin CR, Loo LK, Singh S, Uthlaut B, Glod SA, Fondhan E, McManamon A, Wallach SL, Hamad K, Walsh K, Gentilesco B. Nested Domains: A Global Conceptual Model for Optimizing the Clinical Learning Environment. Am J Med. 2019 Jul;132(7):886-891. doi: 10.1016/j.amjmed.2019.03.019. Epub 2019 Apr 3. PMID: 30953633.
3. Bravata DM, Watts SA, Keefer AL, Madhusudhan DK, Taylor KT, Clark DM, Nelson RS, Cokley KO, Hagg HK. Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. J Gen Intern Med. 2020 Apr;35(4):1252-1275. doi: 10.1007/s11606-019-05364-1. Epub 2019 Dec 17. PMID: 31848865; PMCID: PMC7174434.
4. Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American medical students: a pilot study. Int J Med Educ. 2016 Oct 31;7:364-369. doi: 10.5116/ijme.5801.eac4. PMID: 27802178; PMCID: PMC5116369.
5. Bullock 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 Nov;95(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations):S58-S66. doi: 10.1097/ACM.0000000000003628. PMID: 32769459.
6. Rivera 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 Jul 6;17:11166. doi: 10.15766/mep_2374-8265.11166. PMID: 34277932; PMCID: PMC8257750.
7. Bindman 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 on March 29, 2022.
8. Dweck CS. Self-theories: Their Role in Motivation, Personality, and Development. New York, NY: Taylor & Francis; 2013:1-210.
9. Canning 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 Feb 15;5(2):eaau4734. doi: 10.1126/sciadv.aau4734. PMID: 30793027; PMCID: PMC6377274.
10. Theard MA, Marr MC, Harrison R. The growth mindset for changing medical education culture. EClinicalMedicine. 2021 Jun 17;37:100972. doi: 10.1016/j.eclinm.2021.100972. PMID: 34195583; PMCID: PMC8225653.
11. Richardson D, Kinnear B, Hauer KE, Turner TL, Warm EJ, Hall AK, Ross S, Thoma B, Van Melle E; ICBME Collaborators. Growth mindset in competency-based medical education. Med Teach. 2021 Jul;43(7):751-757. doi: 10.1080/0142159X.2021.1928036. Epub 2021 Jul 10. PMID: 34410891.
12. Edmondson AC, Zhike L. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annu. Rev. Organ. Psychol. Organ. Behav. 1, no. 1 (2014): 23-43.
13. Tsuei SH, Lee D, Ho C, Regehr G, Nimmon L. Exploring the Construct of Psychological Safety in Medical Education. Acad Med. 2019 Nov;94(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 58th Annual Research in Medical Education Sessions):S28-S35. doi: 10.1097/ACM.0000000000002897. PMID: 31365407.
14. Torralba KD, Jose D, Byrne J. Psychological safety, the hidden curriculum, and ambiguity in medicine. Clin Rheumatol. 2020 Mar;39(3):667-671. doi: 10.1007/s10067-019-04889-4. Epub 2020 Jan 4. PMID: 31902031.
15. Agency for Healthcare Research and Quality. Creating Psychological Safety in Teams. 2018. (available at)  https://www.ahrq.gov/evidencenow/tools/psychological-safety.html. Accessed on January 20, 2022.
16. Greenwald AG, Banaji MR. The implicit revolution: Reconceiving the relation between conscious and unconscious. Am Psychol. 2017 Dec;72(9):861-871. doi: 10.1037/amp0000238. PMID: 29283625.
17. Backhus LM, Lui NS, Cooke DT, Bush EL, Enumah Z, Higgins R. Unconscious Bias: Addressing the Hidden Impact on Surgical Education. Thorac Surg Clin. 2019 Aug;29(3):259-267. doi: 10.1016/j.thorsurg.2019.03.004. Epub 2019 May 17. PMID: 31235294.
18. Sukhera J, Watling C. A Framework for Integrating Implicit Bias Recognition Into Health Professions Education. Acad Med. 2018 Jan;93(1):35-40. doi: 10.1097/ACM.0000000000001819. PMID: 28658015.
19. Boscardin CK. Reducing Implicit Bias Through Curricular Interventions. J Gen Intern Med. 2015 Dec;30(12):1726-8. doi: 10.1007/s11606-015-3496-y. PMID: 26311199; PMCID: PMC4636582.
20. Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder AM, Nadal KL, Esquilin M. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007 May-Jun;62(4):271-86. doi: 10.1037/0003-066X.62.4.271. PMID: 17516773.
21. Torres L, Driscoll MW, Burrow AL. Racial microaggressions and psychological functioning among highly achieving African-Americans: A mixed-methods approach. Journal of Social and Clinical Psychology. 2010; 29(10), 1074–1099.
22. Wheeler M, de Bourmont S, Paul-Emile K, Pfeffinger A, McMullen A, Critchfield JM, Fernandez A. Physician and Trainee Experiences With Patient Bias. JAMA Intern Med. 2019 Dec 1;179(12):1678-1685. doi: 10.1001/jamainternmed.
23. Gonzalez 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 Jul 13;17:11168. doi: 10.15766/mep_2374-8265.11168. PMID: 34277934; PMCID: PMC8275619.
24. Bullock 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 Nov 1;96(11S):S71-S80. doi: 10.1097/ACM.0000000000004288. PMID: 34348373.
25. Sotto-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 Jul 31;16:10971. doi: 10.15766/mep_2374-8265.10971. PMID: 32754635; PMCID: PMC7394349.
26. Acquaviva KD, Mintz M. Perspective: Are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations. Acad Med. 2010 Apr;85(4):702–705. doi: 10.1097/ACM.0b013e3181d296c7
27. Krishnan 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 Apr;94(4):550-555. doi: 10.1097/ACM.0000000000002589. PMID: 30640269.
28. Gay and Lesbian Medical Association (GLMA). Guidelines for care of lesbian, gay, bisexual, and transgender patients. San Francisco, CA: Gay and Lesbian Medical Association. 2006. https://www.glma.org/_data/n_0001/resources/live/GLMA guidelines 2006 FINAL.pdf . Accessed on January 21 2022.
29. Aiyer  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.  aamc.org/initiatives/coreepas /publicationsandpresentations Accessed on January 21 2022.
30. Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009;31(11):990-993. doi:10.3109/01421590902960326
31. Amutah C, Greenidge K, Mante A, Munyikwa M, Surya SL, Higginbotham E, Jones DS, Lavizzo-Mourey R, Roberts D, Tsai J, Aysola J. Misrepresenting Race - The Role of Medical Schools in Propagating Physician Bias. N Engl J Med. 2021 Mar 4;384(9):872-878. doi: 10.1056/NEJMms2025768. Epub 2021 Jan 6. 
32. Olufadeji A, Dubosh NM, Landry A. Guidelines on the use of race as patient identifiers in clinical presentations. J Natl Med Assoc. 2021 Aug;113(4):428-430. doi: 10.1016/j.jnma.2021.02.005. Epub 2021 Mar 18.
33. Potter LA, Burnett-Bowie SM, Potter J. Teaching Medical Students How to Ask Patients Questions About Identity, Intersectionality, and Resilience. MedEdPORTAL. 2016 Jun 24;12:10422. doi: 10.15766/mep_2374-8265.10422.
34. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882. doi: 10.1056/NEJMms2004740. Epub 2020 Jun 17.
35. Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020 Oct 10;396(10257):1125-1128. doi: 10.1016/S0140-6736(20)32076-6. PMID: 33038972; PMCID: PMC7544456.
36. Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, Gupta A, Kelaher M, Gee G. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS One. 2015 Sep 23;10(9):e0138511. doi: 10.1371/journal.pone.0138511.
37. Karliner 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 Apr;42(2):727-54. doi: 10.1111/j.1475-6773.2006.00629.x.
38. Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012 Oct;27(10):1294-9. doi: 10.1007/s11606-012-2041-5. Epub 2012 Apr 18. PMID: 22528618; PMCID: PMC3445680.
39. Chen AH, Youdelman MK, Brooks J. The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond. Journal of General Internal Medicine. J Gen Intern Med. 2007 Nov; 22(Suppl 2): 362–367.
40. Vela MB, Fritz CF, Press VG, Girotti JG. Medical Students' Experiences and Perspectives on Interpreting for LEP patients at two U.S. Medical Schools. Journal of Racial and Ethnic Health Disparities. 2016 June; 3(2) 245-249. 10.1007/s40615-015-0134-7.
41. Flores G, Laws M, Mayo S, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics.2003;111(1):6–14.
42. Aitken G. Medical Students as Certified Interpreters. AMA J Ethics. 2019 Mar 1;21(3):E232-238. doi: 10.1001/amajethics.2019.232.
43. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015 Feb 1;15:6. doi: 10.1186/s12909-015-0290-9.
44. Banaji MR, Greenwald AG. Blindspot, Hidden Biases of Good People. New York, NY: Delacorte Press; 2013:1-254.
45. Christakis NA. Don't just blame the system. BMJ. 2008 Apr 5;336(7647):747. doi: 10.1136/bmj.39534.461134.59.
46. Colson ER, Pérez M, Blaylock L, Jeffe DB, Lawrence SJ, Wilson SA, Aagaard EM. Washington University School of Medicine in St. Louis Case Study: A Process for Understanding and Addressing Bias in Clerkship Grading. Acad Med. 2020 Dec;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S131-S135. doi: 10.1097/ACM.0000000000003702.
47. Lucey CR, Hauer KE, Boatright D, Fernandez A. Medical Education's Wicked Problem: Achieving Equity in Assessment for Medical Learners. Acad Med. 2020 Dec;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S98-S108. doi: 10.1097/ACM.0000000000003717.
48. Benoit LJ, Travis C, Swan Sein A, Quiah SC, Amiel J, Gowda D. Toward a Bias-Free and Inclusive Medical Curriculum: Development and Implementation of Student-Initiated Guidelines and Monitoring Mechanisms at One Institution. Acad Med. 2020 Dec;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S145-S149. doi: 10.1097/ACM.0000000000003701.
49. Plews-Ogan ML, Bell TD, Townsend G, Canterbury RJ, Wilkes DS. Acting Wisely: Eliminating Negative Bias in Medical Education-Part 2: How Can We Do Better? Acad Med. 2020 Dec;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S16-S22. doi: 10.1097/ACM.0000000000003700.