Exploring the Telephone Call Experience of Patients with Non-English Language Preference in Primary Care vs. Specialty

Abstract

Background

Latine people, comprising 18.5% of the US population, constitute the largest ethnic minority group, with nearly one-third self-identifying as having non-English language preference (NELP). Despite the importance of the telephone in health care access, there is limited understanding of how NELP patients navigate telephone calls with primary and specialty care clinics.

Objective

This qualitative study aims to capture how Spanish speakers with NELP characterize their telephone call experiences with primary and specialty care clinics.

Design

Semi-structured interviews were conducted with 24 Spanish-speaking participants from primary care clinics with a sizeable proportion of patients who prefer to communicate in a language other than English at an urban academic medical center in Boston, MA.

Participants

Participants were selected from primary care clinics that were well-equipped to serve Spanish-speaking patients. A total of 24 Spanish-speaking patients with NELP, mainly women (83%), with a mean age of 55.8 years, participated. They represented diverse countries of origin, with an average length of time in the USA of 21.7 years.

Approach

Interview questions prompted participants to describe their telephone call experiences with front desk staff, with attention to interpreter availability, ancillary assistance, health outcomes stemming from a lack of language services, and emotional consequences of language discordance on calls.

Key Results

Patients perceived primary care clinics as providing familiarity and language concordance during telephone interactions, contrasting with specialty care clinics, seen as sources of monolingual English communication. Participants utilized various strategies, such as requesting interpreters, using concise English phrases, or seeking assistance from acquaintances, relatives, or primary care clinic staff, to mitigate language barriers.

Conclusions

The findings underscore significant challenges faced by Spanish-speaking patients with NELP in ambulatory specialty care telephone calls. The study emphasizes the importance of creating inclusive multilingual telephone environments, standardizing interpreter access, and reflecting the diversity of the communities served.

INTRODUCTION

Patients with non-English language preference (NELP) contend with health disparities that are independently driven by language.^1–3 Latine people constitute 18.5% of the USA, the largest ethnic minority group, with nearly one-third of this population self-identifying as having NELP.^4–6 Language has been the most frequently reported challenge among Latine patients in navigating a health care system that was designed for English speakers.⁴ Per Title VI of the Civil Rights Act of 1964, federally funded health institutions are mandated to offer interpreter services to patients with NELP.^7,8 Yet English can still act as a gatekeeper to care, due in part to inconsistent use of professional interpreters,^9,10 varying rates of reimbursement for interpreter services,¹¹ and an insufficiency of professional interpreters.^1,12–15 Substantial research has investigated language barriers in clinical encounters, but less attention has been given to telephone communications. When communication between patients with NELP and health care is conducted via telephone calls, already suboptimal access can become further compromised.

For patients with NELP, the interaction with an automated telephone system or telephone operator in English can represent an initial, non-negligible barrier to health care. Even telephone calls characterized by language concordance are complicated by the absence of visual cues.¹⁶ Interacting in English can impose an added layer of distance for callers with NELP and potentially lead to an inferior patient experience and worse outcomes. Previous research on health-related telephone calls initiated by patients with NELP has centered on acute care situations. Dai et al.¹⁷ found that parents with NELP were nine times more likely to elect an emergency department visit for their child instead of contacting a specialist by telephone. Njeru et al.¹⁸ determined triage calls by this patient population to be lengthier and more often initiated by a care partner. In a survey of 911 telephone operators, 78% of respondents reported communication challenges in calls with patients with NELP, and dispatchers perceived these obstacles to negatively impact care.¹⁹

There is a documented need to better understand how patients with NELP experience barriers to access in non-acute settings.²⁰ For example, Uscher-Pines et al. employed a secret-shopper design, with data collectors acting as English- or Spanish-speaking callers seeking behavioral health services, and found that 22% of Spanish-speaking callers were hung up on.²¹ The documentation of limited portal use among patients with NELP bolsters the relevance of telephone calls for increased access to health care.^22,23 We center our investigation on the understudied yet significant context of telephone calls with primary and specialty care clinics, both those placed and received by Spanish-speaking patients with NELP. This research builds on our previous work that examined language access in automated telephone menu recordings and found specialty care clinics less likely to offer non-English language recordings.²⁴ In collecting the first qualitative data, to our knowledge, on the characterization of telephone calls in situations of non-acute care by patients with NELP, we sought to explore whether a distinction between primary and specialty care clinics was also salient in participants’ descriptions of telephone calls with front desk staff.

METHODS

Study Setting

Participants were selected from two primary care clinics with a sizeable proportion of patients who prefer to communicate in a language other than English, with roughly 30% having a documented language preference of Spanish at one clinic and 45% at the other. These primary care clinics are part of an integrated health care system wherein providers refer patients from primary to specialty care clinics within the system. The selected primary care clinics are equipped to serve Spanish-speaking patients owing to their bilingual telephone answering services and majority bilingual staff. The patient sample consequently did not require interpreter services when communicating by telephone with front desk staff at the selected primary care clinics. On the other hand, we surmised that front desk staff at specialty care clinics would routinely need to connect with interpreter services when interacting with patients with NELP via the telephone.

We sought to understand whether the primary care clinics’ bilingual strengths would contrast with any linguistic barriers to telephone communication perceived by patients in ambulatory specialty care. Our interest in whether such a distinction would be voiced by participants stems from our clinical experience working with this patient population and our familiarity with literature on the barriers to care they face.

Study Design

This study was approved by the Mass General Brigham’s Institutional Review Board. We conducted semi-structured interviews with Spanish-speaking patients with NELP to understand their experiences in telephone calls with front desk staff from ambulatory clinics. Using electronic health record (EHR) data, we identified patients who had Spanish as their preferred language, were flagged as needing an interpreter, and had been seen at their primary care clinic within 60 days prior to the date when the EHR was queried. This yielded a total of 1776 patients. We performed a chart review of randomly selected patients to confirm a visit with a specialty care clinic within the previous 12 months. This process was repeated three times, yielding a total of 83 participants.

Invitations were sent in Spanish via postal mail and follow-up telephone calls were placed in Spanish a minimum of 2 weeks later. Of the 83 participants contacted by mail, 24 agreed to interviews, 12 declined, 2 had invalid phone numbers, and the rest were unreachable. Those who agreed to take part were interviewed immediately following the telephone invitation to participate, when available, or were telephoned again at a time that was convenient to them.

Two researchers (ML, EL) independently formulated questions in Spanish for the interview guide, subsequently comparing and refining their versions into a unified guide. The third researcher (JR) was consulted for feedback on this guide and its later revision. Accuracy was verified by having the interview guide back-translated to English by a professional translator unaffiliated with the research team. The guide was then piloted on a potential participant. Following this initial interview, the questions were rephrased to improve reliability. The revised interview guide was then employed with a second potential participant and some final, minor revisions were subsequently made. In terms of content, the questions were designed to elicit participants’ experiences when communicating with front desk staff at primary and specialty care clinics via telephone calls (see Table 1 for sample questions). The guide specifically inquired about the availability of interpreters, patients’ need for ancillary assistance when communicating via the telephone, any suboptimal outcomes to their health resulting from language discordance over the telephone, and the emotional dimension of telephone calls.

Table 1.

Sample Items from the Back-translated, Semi-structured Interview Guide

• How often do you use the phone to make calls in English? Probe: For what purposes do you do so?

• Have you communicated with your primary care/specialty doctor’s office by phone? Can you describe your last experience?

• When you receive a call from your primary care/specialty doctor’s office, in what language does the caller speak? Can you describe your last experience?

• How are you treated by the front desk staff at your primary care/specialty clinic?

• When you call a primary care/specialty clinic, are you successful in reaching the front desk staff? Probe: What language do they normally speak to you in?

• Have you used family/friends for help because front desk staff at primary care/specialty clinics does not speak Spanish? Probe: Can you tell me more about that?

• What suggestions do you have for improving phone communication for non-English speakers and clinics?

• How do you prefer to communicate with health services? Probe: Why is that the case?

• How easy is it to ask for an interpreter via the phone when one is not offered by front desk staff?

• Have you ever chosen not to call a clinic due to concerns about language barriers? Probe: Can you tell me more about that?

• Have you lost or delayed a medical appointment due to language barriers over the phone? Probe: Can you tell me more about that?

Primary vs specialty care questions were asked during different portions of the interview

The semi-structured interview was preceded by survey questions, which collected demographic information about participants’ age, language spoken at home, sex, time since arrival to the USA, and self-reported health status, as well as their preferred communication method when engaging with health care in non-acute circumstances.

Data Collection

Interviews were conducted via telephone and in Spanish by a researcher with native proficiency in the language (ML) between October 2022 and May 2023. All participants were asked for verbal consent to confirm informed voluntary participation prior to the interview. All interviews were recorded and later transcribed verbatim by a professional service. Participants were provided compensation for their participation in the form of a gift card.

Analysis

For thematic analysis, the research team adopted the constant comparative method,²⁵ moving from open to axial phases of coding.²⁶ An initial codebook was developed after two researchers (ML, EL) independently and inductively coded a segment of the interviews, and coding with gradual refinement in labels was constant. After the development of initial codes, the two coding researchers met in consultation with the third researcher (JR) to discuss the codebook and reconcile discrepancies. The final codebook resulted from the iterative coding of all interviews. Through this process, similar codes were subsumed into subthemes and themes through constant comparison. Analysis of the data was supported by NVivo software (version 14.23).

RESULTS

Participant characteristics, collected through the survey portion of the interview, are summarized in Table 2. Of the 24 individuals interviewed, 20 (83%) self-reported limited English proficiency (defined as “not speaking English” or “not speaking English well”). Most participants were women (N = 20; 83%); their mean age was 55.8 years (SD 13.9) and mean length of time in the USA was 21.7 years (SD 12.8). A preference to communicate with the health care system by telephone calls (as opposed to patient portal applications or postal mail) was expressed by 18 (75%) of the participants. All but one participant had public insurance, as verified in the EHR.

Table 2.

Participant Characteristics

Characteristics	N	%
Age
18–35	3	13% (3/24)
36–50	5	21% (5/24)
51–64	9	38% (9/24)
65–74	7	29% (7/24)
Sex
Male	4	17% (4/24)
Female	20	83% (20/24)
Language spoken at home
Spanish	24	100% (24/24)
Place of birth
Colombia	1	4% (1/24)
Dominican Republic	17	71% (17/24)
Ecuador	1	4% (1/24)
Guatemala	1	4% (1/24)
Honduras	1	4% (1/24)
Puerto Rico	3	13% (3/24)
Years in the USA
0–10	5	21% (5/24)
11–20	6	25% (6/24)
21–30	7	29% (7/24)
31–40	4	17% (4/24)
41–50	2	8% (2/24)
Self-reported health
Very poor	1	4% (1/24)
Poor	1	4% (1/24)
Average	12	50% (12/24)
Good	7	29% (7/24)
Excellent	3	13% (3/24)
Self-reported English proficiency
Does not speak	11	46% (11/24)
Not well	9	38% (9/24)
Well	4	17% (4/24)
Insurance
Public	23	96% (23/24)
Private	1	4% (1/24)

The findings are presented below according to the five salient themes. Illustrative quotes, translated from Spanish, are included throughout to document the participants’ perspectives in their words.

1. Bilingual Primary Care Clinics as Familiar and Accessible in Contrast to Specialty Care Clinics

Participants described ease in telephone communications with their primary care clinics, which they attributed to bilingual staff. Interviewees commented on the linguistic and cultural relatability of primary care staff (those at “my clinic,” participant 5), who spoke “my language” (participants 5, 12, 20, 23), were representative of “my people” (participant 5), and “seem Hispanic” (participant 10). One participant cited the bilingual aspect of her primary care clinics as the reason why she became a patient there: “I chose it because Spanish is spoken there” (participant 23). In contrast, participants described specialty care clinics as monolingual in English (e.g., “At [the specialty care clinic], they speak English,” participant 9) or, at most, minimally bilingual (“At [the specialty care clinic] few people speak Spanish,” participant 10). One participant placed particular emphasis on the monolingualism of specialty care clinic staff: “The secretaries of [the specialist doctor] only speak English English English English […] It’s difficult for me because it’s English- all those people they have there are English. They hardly speak Spanish” (participant 2). While primary care sites were described as linguistically relatable on the telephone, they were also characterized as friendlier, in contrast to specialty care. One participant went as far as to report perceived discrimination in specialty phone communications: “[the specialty care clinic] is a little more racist” (participant 10).

Several participants underscored the importance of employing staff who can communicate with patients in their language of choice: “Seeing as this is a country of immigrants and that we are a very large community, the hospitals or specialty care clinics should hire people who speak Spanish, like they do at [the primary care clinic]” (participant 16). Another participant echoed this recommendation: “I think that in every specialty there should be a secretary who speaks Spanish […] This would be significant for Spanish speakers- in every hospital department it’s important to have even just one person who speaks Spanish” (participant 24).

• 2.Suboptimal patient experiences in calls with specialty care

While most participants reported that barriers in telephone calls resulted in no harm, various suboptimal patient experiences with specialty care were voiced.

• Limited access to information. The lack of multilingual staff at specialty care clinics compromised patients’ ability to obtain the details needed to fully engage in their care via telephone calls. As one participant reported, “They called me, and I understood them because they said ‘colonoscopy,’ so I said I didn’t speak English. They said something but I didn’t understand so they hung up. From there, I knew nothing, and they didn’t call me back” (participant 22). Even when patients were able to partially understand information conveyed in English over the telephone, they were left with uncertainty about specifics related to their care. Another participant commented, “All the time they would call me in English. I knew that they were talking about an appointment, but I didn’t know what they appointment was for. And for that reason, I only partially understood” (participant 4).

• Delays in care. One participant noted an inability to solve her issue on the day she called a specialty care clinic: “Since they didn’t speak English, I said ‘well I will call another day” (participant 1). Delays also resulted from missed appointments owing to language barriers, as noted by a participant: “I missed an appointment a while ago for my urology study because they would call and talk to me in English, and I would say ‘No English. No English.’ And I would call, and the recording would play in English, and I would say ‘ok then…’” (participant 2). While ancillary assistants could facilitate calls, they were not always readily available: “Well sometimes I hang up and wait until my husband is present” (participant 1).

• Diminished agency. Some participants explained that language barriers prompted them to accept suboptimal alternatives in specialty care, as they could not advocate for their preferences. One participant shared, “For my post-op appointment, I wanted something early, but my appointment was very late, and since I could not explain that I can’t make it at that time I had to get what they offered me because no one spoke Spanish” (participant 24). Another participant acknowledged that her agency was compromised by her need to have her husband communicate with specialty care on her behalf: “My husband doesn’t say what I want. As a patient I have to say what I need and what I feel” (participant 2).

• Reluctance to call. Some participants reported electing not to place a telephone call to specialty care owing to language discordance, even when they perceived an immediate need to do so. For example, one interviewee commented, “There was one [appointment] that I lost not so long ago […] for [the specialty care clinic]. I couldn’t make it because […] my job wouldn’t let me, I didn’t have anyone to cover me, at the time my children weren’t around and […] I wanted to cancel in the morning. I didn’t have anyone close by to help me, so I had to lose it and I didn’t cancel it so they could reschedule me” (participant 14). Another participant characterized calls with specialty care clinic staff as cumbersome enough to suspend her efforts to communicate by telephone on more than one occasion: “I honestly couldn’t communicate with them. I had surgery and I wanted to know what day I needed to come back for the appointment and, honestly, I didn’t know […] That happened to me two times, I said ‘I’m done calling’” (participant 10). Another time, when seeking guidance about a wound, the same participant found telephone calls to be too challenging to be deemed worthy of continued pursuit: “I can tell [the specialty care clinic] staff little words, like the typical, but there are times when after they’ll ask you something and I don’t even know how to respond to them, so I try not to call. I call if it’s necessary, like for example for my wound, I wanted like some questions about that, but I couldn’t contact anyone and I let it go, I’ve dropped it” (participant 10).

• Emotional distress. Participants reported feelings of discomfort when spoken to by front desk staff at specialty care clinics in English over the telephone. For example, interviewees commented: “It makes me embarrassed” (participant 1); “I feel uncomfortable because I don’t understand what they are telling me” (participant 2); “I feel like frustrated” (participant 7); “I get sad because I don’t understand a lot” (participant 9); “There are things that you understand, but you don’t know how to answer, it feels like a jam because you don’t know what you are going to say” (participant 10). Participants also experienced inconvenience and emotional distress from having to wait for information to be shared with them in Spanish. One interviewee commented, “Sometimes I don’t get an immediate response” (participant 14). Another participant reported the emotional toll of language discordance in calls with specialty care: “I wasn’t even sleeping, I lose sleep, I have this worry about not being able to talk to the secretary so she can tell me my test results, if they were good, if they were bad” (participant 24).

• 3.Varied interpreter availability

Participants did not need an interpreter when communicating by telephone with their bilingual primary care clinics. By contrast, they expressed a need for an interpreter in calls with specialty care clinics and reported varied availability and consequent wait time to obtain one. Some participants described a quick, even instantaneous, process to connect to an interpreter (e.g., “They do it quickly […] They do it immediately,” participant 6), while others characterized interpreter availability as more unpredictable (e.g., “Sometimes, yes, they’ll get back to me, but other times no, and I find myself on hold,” participant 14). Reported wait times ranged from minutes to hours to the following day–to indefinite: “You keep waiting for the call, they never call you back. With [the specialty care clinic] I have this problem […] Lately they almost never return my call” (participant 4). In the same vein, another participant commented on the persistence required of her to establish telephone contact: “Sometimes they call you back with an interpreter but sometimes nothing, so one must keep trying a lot” (participant 16). Overall, participants expressed a desire for greater interpreter availability. One interviewee stated, “I would like there to be more interpreters for people who do not speak English” (participant 11).

• 4.Reinforcement of linguistic hierarchies

While some participants lamented a lack of Spanish speakers on the telephone or recommended that multilingual staff be hired, they did not place the blame for language discordance on the system, as evidenced by participant 5’s comment: “[I feel] uncomfortable, but it is not [the secretary’s] fault.” Another participant included an apology in her reported speech to the specialty care clinic: “No English. Sorry” (participant 9). Moreover, some participants explicitly self-identified as having limited English proficiency and placed the onus of correcting language discordance on themselves. For example, one participant commented, “I try to talk to [the specialty care clinic], but always letting them know that my English is very poor. I speak little English” (participant 3). Another reflected, “I don’t have very good command of the language yet. I don’t know and I need to practice it because it’s in English […]. So, I need to practice it, to wait for my daughter to come so she can help me to practice it, to know how to use it” (participant 4).

• 5.Patients’ strategies to overcome language barriers

Language discordance in telephone calls can prompt patients to turn to suboptimal measures to bridge communication gaps with specialty care clinics. Although some participants reported requesting an interpreter (e.g., “Intérprete please,” participant 10), others resorted to different approaches.

Several participants expressed familiarity with pragmatic English phrases that facilitate being connected to a Spanish speaker: “I say ‘No English. Spanish?’ And they hang up and call me back with someone who speaks Spanish” (participant 2). Similarly, another participant commented, “‘for June 18, for August 13,’ that is something they understand well; they know I’m calling about an appointment and I get it” (participant 3). Some participants reported waiting for ancillary help for calls with live staff as well as navigation of phone trees (e.g., “There is a lady who speaks a little English and she tells me this is the option for Spanish so press here,” participant 2). The same participant reported enlisting help from primary care staff as well: “I call [my primary care clinic] and I ask the secretary to call [the specialty care clinic] for me” (participant 2).

When asked why they turn to friends and family instead of using interpreters, some participants cited convenience: “Almost always when I need to call the hospital my daughter does so” (participant 15). Another participant reported how a communication impasse with specialty care clinics on the telephone led her to present at the hospital to seek assistance in person: “I had an appointment in January […] for a study of my stomach, and still, now we are in February and many days ago I should have learned about this, the results of this analysis, to make an appointment for each surgery. And I called the secretary’s office, and I couldn’t talk with them, and I didn’t even know what to do. In the end, I went to the hospital, and I told them to call this number, I gave them the number of the doctor’s secretary” (participant 24). Although they have developed strategies to navigate language barriers, participants spoke to the need to respect preferred patient language: “If the patient prefers Spanish, Portuguese, French, whatever language it may be, the primary language that they wish to speak should always be in their record” (participant 21).

DISCUSSION

This qualitative study highlights the challenges faced by patients with NELP when interacting with front desk staff via telephone calls. Interviewees described worse non-clinical telephone call experiences with specialty care clinics compared to primary care clinics owing to a lack of multilingual staff and unpredictable interpreter wait times. As illustrated by participants’ comments, obstacles experienced in calls with clinics can risk further eroding patients’ trust in the health care system charged with their care, an issue that has been well-documented in the Latine population with NELP.^4,27–30

Previous NELP studies focused on telephone communications have highlighted the added barrier posed by the telephone, with patients electing ED visits over telephone triage,⁶ experiencing longer triage calls,⁷ and having their care compromised in 911 calls.⁸ Building on our previous work documenting worse availability of non-English telephone recordings in specialty care clinics compared to primary care clinics,²⁴ the present study found that, even when patients with NELP connect to front desk staff, the experience remains suboptimal with specialty care clinics. Participants described telephone calls with specialty care clinics as predominantly monolingual in English and often laden with frustration. Further, the issues that they encountered, sometimes resulting in challenges to specialty care access, can serve to contextualize previous studies documenting the lower use of specialty care, disparities in times to appointment, cancer screenings, and the completion of necessary surgical treatments.^31–35

The purposeful comparison of participants from primary care clinics equipped to serve their NELP needs via the telephone and specialty care clinics not enacting the same multilingual capabilities drew a sharp contrast in the patient experience. A lack of reservations about initiating contact for health care needs should represent a basic standard of patient care. That participants expressed no concerns when getting in contact with their primary care clinics via telephone calls suggests that efforts to create linguistically inclusive telephone environments can promote patient engagement and trust. On the other hand, as voiced by participants, challenges in communication via telephone calls with specialty care clinics due to the unavailability of language concordance by front desk staff can limit access and exact a preventable emotional burden. Moreover, the reinforcement of system-patient hierarchies is accentuated by patients’ self-assumed responsibility, as expressed by some participants, for rectifying language discordance. We reiterate Showstack’s¹⁰ assertion that “[p]atients don’t have language barriers; the healthcare system does.”

Although there is an ongoing and warranted impetus to promote access to health care via patient portal applications, it is important to recognize that enrollment of patients with NELP has lagged.²² As exemplified by most of our participant sample, some patients with NELP may continue to prefer communication via telephone calls. The lack of language concordance in telephone calls with front desk staff at specialty care clinics that we observed in our data advances an implicit message about respect and belonging,^30,36 namely, that patients’ preferred language may not be prioritized in a health institution’s inclusion efforts.³⁷ As such and to create equitable multilingual milieus, health systems should invest in ensuring that health access via telephone calls is as seamless an experience as possible for all patients, with special attention to their preferred language.

We share participants’ desire to imagine a different approach to acknowledging patients with NELP on the telephone. We envision (a) health systems with more multilingual employees who can attend to the growing linguistic diversity³⁸ of the patient populations they serve and (b) automated phone systems capable of recognizing patients’ telephone numbers and responding with a recording in their preferred language when they use the telephone number on record or (c) telephone systems with a linguistic diversity that is representative of the communities served by health institutions, with recordings in the most common languages spoken by the populations served. A summary of our findings was shared with this study’s health system and the equity leadership has taken steps to support ongoing language access initiatives, including a planned central telephone routing system where language is queried at the outset of the call, with interpreter support as needed. This work can inform similar efforts at other health care systems as they move towards language equity.

This study is not without limitations. We did not seek to understand differences by specialty. While it could be worthwhile to explore potential differences across specialties, efforts should ultimately focus on standardizing language services across systems in their entirety. It is also important to acknowledge that the population of patients with NELP constitutes an increasingly multilingual and diverse group³⁹ and the Spanish-speaking patients we interviewed may have different experiences than speakers of other languages. Nevertheless, the clear need to improve language access for patients with NELP is even more noteworthy given that our study focused on those whose preferred language was the most common non-English language in the Boston area. That language access for this sizable non-English language population remains complicated suggests that the situation would be even more dire for speakers of less commonly spoken languages.

CONCLUSION

This study highlights challenges encountered on telephone calls with specialty care clinics for Spanish-speaking patients with NELP. While it is unfortunately not surprising to uncover obstacles to care experienced by this patient population, it is striking that a signature communication technology—the telephone—continues to pose significant access problems in the twenty-first century. This study underscores the importance of creating welcoming multilingual spaces beyond the clinic, standardizing interpreter access for patients with NELP, and ensuring that a diverse workforce can provide language-concordant care not only in person but also by telephone.

Funding

Dr. Linares’s effort was supported by grant number T32HP32715 from the HRSA. Dr. Rodriguez was supported by grant K23MD016439 from the NIMHD. Additionally, we received financial support for this project from the Leadership for Health Equity Pathway at Brigham and Women’s Internal Residency Program and a United Against Racism grant from the Mass General Brigham Centers of Expertise.

Data Availability

The data are not publicly available due to privacy restrictions.

Declarations:

Conflict of Interest:

The authors declare that they do not have a conflict of interest.