Insights and interventions for improving cultural humility towards Asian American, Native Hawaiian and Pacific Islander populations in medical curricula: a qualitative case study

Abstract

Objectives

The Asian American, Native Hawaiian and Pacific Islander (AANHPI) community is the fastest-growing racial/ethnic population in the USA. Previous research identified that medical students perceived a lack of exposure to AANHPI patients and topics in medical school curricula; however, there remains a lack of potential interventions to address this need. The goal of our study is to present a case study for identifying interventions in medical school curricula that improve cultural humility-based training for providing medical care for AANHPI populations.

Design

In this qualitative study, authors conducted four virtual focus groups with 15 medical students at a single institution to identify curricular interventions. The authors then conducted virtual semistructured interviews with eight medical educators one-on-one to explore the feasibility of the proposed interventions. Data were analysed using qualitative thematic analysis, and analysis was performed with ATLAS.ti.

Setting

Medical students and medical educators based at medical institutions in the USA.

Participants

15 medical students and eight medical educators participated in the study.

Results

All medical students (n=15) and educators (n=8) noted that there is limited engagement of AANHPI communities in current medical curricula and limited curricular components that address the diversity within the AANHPI umbrella. Medical student focus groups identified three interventions to improve cultural humility-based training for treating AANHPI patients: reflection spaces, community engagement and clinical training on documenting cultural needs. Educators supported the feasibility and importance of these interventions to prepare students to work with not only AANHPI patients but also with patients of other diverse backgrounds.

Conclusion

AANHPIs represent a heterogeneous population consisting of unique cultural heritages. Our research demonstrates the importance of highlighting this community in cultural humility curricula to provide an example of how to consider and appreciate diversity in patient populations. In this paper, we present student and medical educator-supported curricular interventions that not only increase awareness of issues impacting AANHPI communities, but also emphasise building skills of self-reflection, lifelong learning and empathy that are applicable to patients of all backgrounds.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Our study used qualitative methods with live interviews during which interviewers were able to adapt and modify questions based on participants’ responses, thus allowing for nuanced exploration and surfacing novel insights regarding curricular interventions.

• Focus groups allowed for multiple, diverse perspectives, enhancing participants’ reflection of experiences and brainstorming of interventions.

• Student focus groups were conducted at a single institution and did not have a diverse ethnic racial background (13/15 had an Asian American, Native Hawaiian and Pacific Islander background), so our sample population may not be representative of medical students nationally.

• The study purposively sampled educators involved in diversity, equity and inclusion initiatives and featured a small sample size.

Introduction

The Asian American, Native Hawaiian and Pacific Islander (AANHPI) community had the fastest population growth of all racial and ethnic groups in the USA between 2000 and 2019, growing by nearly 8.4 million individuals.¹ The AANHPI population is diverse, with subpopulations having origins in more than 20 countries across the Asian continent and an estimated 54% identifying as immigrants.² Compared with other major racial groups in the USA, AANHPIs have the largest income disparity within the population, with the top 10% income bracket earning nearly 11 times more than those in the bottom 10%.³ Research focused on the AANHPI community demonstrates disparities in cancer fatalities, mental healthcare utilisation and hearing care, highlighting the importance of a culturally humble workforce to address these inequities.4,6

In medical education, cultural humility is increasingly recognised as an important skill that enables physicians to treat patients of all backgrounds with respect and empathy using effective and reflective communication skills.⁷ Importantly, we distinguish ‘cultural humility’ from ‘cultural competency’. The term cultural competence is loosely defined as the ability to understand and interact with individuals of diverse backgrounds and cultures in ways that address potentially unique needs. This suggests that healthcare providers can be competent in a culture based on an understanding of a set of beliefs and values, generating a static view of culture that can perpetuate negative stereotypes and overshadow diversity within cultures.⁸ On the other hand, we define cultural humility as a process encompassing self-reflection on, recognising one’s limitations with and a willingness to learn about different belief systems, enabling providers to empower patients to express their needs and goals.⁸ Cultural humility is a process-oriented approach for life-long learning that encourages self-exploration and emphasises patient-centred care more so than the content-oriented cultural competency approach.

Despite the increasing population and diversity of AANHPIs, medical education in cultural humility for this population is lacking.⁹ Previous work has explored medical students’ self-perceived knowledge and attitudes toward AANHPI patients, with medical students reporting a lack of exposure to AANHPI populations in the medical school curriculum and clinical experiences as the main challenge to learning about AANHPI health.¹⁰ However, no study to date has employed qualitative methods to leverage the perspectives and experiences of medical students and medical educators to ideate solutions to this curricular gap.

The purpose of our qualitative study is to identify student-ideated interventions to improve cultural humility training in medical school curricula for providing medical care to AANHPI populations. In this study, Johns Hopkins University School of Medicine (JHUSOM) serves as a case study for using medical student focus groups to identify such interventions. Additionally, we aim to assess the feasibility of these interventions through interviews with medical educators at and outside of JHUSOM.

Thus, our study seeks to answer the following questions: what interventions are medical students and medical educators interested in to improve cultural humility training for patient care for AANHPI individuals? How feasible are these interventions to integrate into current medical school curricula?

Methods

Using focus groups of medical students at JHUSOM, we assessed medical students’ perceptions of the medical school curriculum to identify gaps and devise solutions in cultural humility training related to AANHPI patients. Next, we assessed the feasibility of these solutions and reflected on current initiatives in medical institutions to address AANHPI cultural humility in one-on-one interviews with medical educators.

Medical student focus groups

Medical students from JHUSOM were recruited via email advertisement to school-wide listservs. Inclusion criteria were defined as any medical student actively enrolled in JHUSOM who consented to participate. Medical students were separated into focus groups based on stage of training (preclinical or clinical) to facilitate targeted discussions. Preclinical training at JHUSOM consisted of both first and second-year curricula. Clinical training involved third and fourth-year curricula. Four virtual focus groups, with 4–6 participants each, were facilitated by a research team member (CI) over Zoom. At the beginning of each focus group, the facilitator introduced participants, explained the purpose of the focus group, confirmed consent to participate and set ground rules. Respondents provided written and verbal consent and received a US$10 Amazon gift card for participating. Interviews occurred for 1 hour.

Interviews were semistructured. The facilitator used a standardised interview guide entailing planned questions and incorporated additional relevant topics as they arose in each session. Discussion topics focused on exposures to cultural humility training for AANHPI groups and suggested changes to the curriculum relevant to their stage of training (preclinical or clinical). CI and SK developed the interview guide based on the results of a previous iteration of this study that assessed student perspectives on the inclusion of AANHPI in medical curricula. Question development was guided by CI and SK’s experiences studying AANHPI health disparities and vetted by SML, a medical educator. The questions were developed to be open-ended to allow participants to freely reflect on their experiences and ideas. The full interview guide can be found in the online supplemental file 1.

Medical educator interviews

Medical educators were recruited through purposive and convenience sampling of medical educators involved in diversity, equity and inclusion (DEI) initiatives across different institutions to receive feedback from educators of diverse backgrounds and institutions located in cities of variable AANHPI population size. A recruitment email was sent to the Association of American Medical Colleges Group on Diversity and Inclusion listserv, with additional individual outreach through snowball sampling. We conducted interviews until thematic saturation was achieved. Eight medical educators were recruited across five institutions (JHUSOM, University of California—San Francisco School of Medicine, New York University Grossman School of Medicine, Medical College of Wisconsin and Washington University in St Louis School of Medicine). Medical educators were not compensated for their time. Four of the medical educators have training backgrounds as physicians, one as a social worker, one as an epidemiologist, one as a scientist and one as a pharmacist. All institutions have a cultural humility curriculum incorporated into their broader medical education. One institution (Medical College of Wisconsin) incorporated a curriculum specifically targeted to AANHPI populations. Respondents provided verbal consent, and interviews were conducted individually over Zoom with a research team member (CC). Interviews lasted between 25 and 42 min.

Interviews were semistructured, with the facilitator using an interview guide entailing planned questions and incorporating additional relevant topics as they arose in each session. The first half of the interview focused on understanding how each institution currently exposes medical students to cultural competency or cultural humility frameworks for working with AANHPI patient populations. Interviewees were prompted to discuss strengths and weaknesses of their institution’s curriculum as well as any potential gaps. The second half of the interview focused on providing feedback on cultural humility interventions generated from the medical student focus groups. Interviewees were first presented with the interventions and then prompted to discuss the feasibility, strengths and drawbacks of each intervention. CI and SK developed the interview guide based on findings from the medical student focus groups, and question development was further informed by SML’s experience as a medical educator. Discussion questions were designed to be open-ended to elicit in-depth reflections from the medical educators. The full interview guide can be found in the (online supplemental file 2).

Qualitative analysis

All medical student focus groups and medical educator interviews were audio-recorded, transcribed verbatim and de-identified. The two data sets were separately analysed using thematic analysis,¹¹ a qualitative method that iteratively identifies, analyses and reports patterns (themes) within data, through the same multistep process described as follows: two researchers (SK, CC) independently reviewed a subset of the data set, inductively identified emergent themes and used these themes to develop an initial codebook. This codebook was applied to the data set and iteratively refined until thematic saturation was reached, defined as the point when no new themes emerged from subsequent analysis. One final codebook was developed and used to code the entire data set (online supplemental files 3-4). Discrepancies in coding were discussed and resolved through consensus with a third auditor (EM). Using multiple coders and an external peer auditor to establish coder agreement has been validated to confirm the reliability of qualitative analysis.¹² Coding was conducted in ATLAS.ti.

All three co–first authors identify as members of the AANHPI community. We acknowledge that our cultural backgrounds and lived experiences may have influenced how we approached, conducted and interpreted this study. To mitigate potential biases, we incorporated multiple strategies to enhance reflexivity and trustworthiness. Notably, our peer auditor, who does not identify as AANHPI, reviewed the coding process and thematic development to provide an external perspective. All members of the research team received formal training in qualitative research methods prior to data collection and analysis.

Patient and public involvement

Participants were involved in research via medical student focus groups and medical educator interviews from June to October 2023. Question guides for both focus groups and interviews were informed by experiences and reflections shared by participants. Patients/public were not involved in the design and conduct of the study, choice of outcome measures, recruitment to the study nor choice of methods/plans for dissemination of the study.

Results

During the focus groups, all participating students expressed little to no experience with curricula specific to AANHPI populations. In total, 15 students participated in the focus groups. 10/15 identified as female and 5/15 as male; 9/15 were in preclinical training, and 13/15 identified as AANHPI. Additionally, 5/15 participants were first-year medical students, 4/15 were second-years, 3/15 were third-years, 1/15 was between third and fourth year and 2/15 students were fourth-years at the time of the focus group. Participants stated that the lack of curriculum related to AANHPI patients was primarily due to a perceived time limitation in the curricula to implement additional training. Furthermore, focus group participants noted that any curriculum that did exist was often reactive, developed in reaction to current events, instead of proactive, and a personal burden was placed on students to educate themselves and their colleagues.

A few students had not heard of the term cultural humility before; however, most students expressed wanting more cultural humility curricula, with potential applications to AANHPIs. A minority of students (1/15) expressed that they did not anticipate a need for additional AANHPI-specific curricula, and a few (3/15) perceived no difference in care between AANHPI and other minority patients. One of these students observed that social determinants of health seemed more prudent than race/ethnicity alone in determining patient care and observed the following:

I’ve seen patients who are Asian, who are really well taken care of, and patients who are Asian, who really were not. And I don’t think the dividing lines [were] whether…they were Asian, I think a dividing line was whether or not they were English speaking, or had social capital, and were able to advocate for themselves, and I think that this is true across a lot of populations. - Participant 10

Students cited the following as examples of curricular components to address AANHPI health: individual topics (notably immigrant health and COVID-19-related AANHPI hate) integrated into medical courses and health disparity curricula, student-led initiatives and extracurriculars, community-engaged research and interpretation training. Proposed interventions leveraging a cultural humility framework were grouped into the following thematic categories: reflection spaces, community-led workshops and training on documenting patients’ language/cultural needs.

Educators noted various challenges in creating an AANHPI-specific curriculum, including the diversity of the AANHPI population, limited time to implement additional training and the need for student expertise in creating and managing curricula. Educators pointed to the strengths of a cultural humility, rather than cultural competency, framework for developing skills applicable to caring for patients from different backgrounds, rather than a specific context; however, they noted system-level challenges limiting a broader cultural shift towards cultural humility, including aligning the medical school’s interpretation of cultural humility with the larger institution’s, as well as limited collaboration on cultural humility within and between institutions.

A recurring theme highlighted in the interviews is that these interventions are not limited nor specific to AANHPI patient populations. However, students and educators noted the importance of applying these interventions to AANHPI populations, given current events (such as rising hate crimes) disproportionately impacting AANHPI populations and the well-documented health disparities between AANHPI groups. Moreover, all educators noted that given the mission of cultural humility curricula to highlight rather than condense the diversity of patient experiences, this approach could help disaggregate the diverse experiences condensed under the AANHPI umbrella and provide insights on developing such curricula for similarly diverse populations. The results of our study provide feasible interventions that highlight the diversity of AANHPI populations, offering a representation of how to effectively apply cultural humility frameworks in medical education for different patient populations.

Ultimately, educators and students felt that despite limited time in the medical curriculum, space could and should be made to incorporate interventions from each of these areas. Each intervention category is elaborated below.

Reflection spaces

Intervention: Students desired dedicated longitudinal time, throughout their training in medical school, with faculty to reflect on patient interactions and the intersection of identity and medicine. Emblematic quotes from focus group participants include:

I think these kinds of cultural things are appropriate anytime, and […] ideally, I would […] make it longitudinal. Why not? That would increase exposure, allow for […] interaction with these kinds of ideas about culture in your community throughout […] different stages of learning, and […] not [make] it seem like it’s some kind of adjunctive optional activity. - Participant 16

I think some things clerkships might be able to do is […] post encounter reflection experiences […] for example, […] there’s [a] lot of diversity, and like a 1000 different things that people do in different ways and we’re not gonna be able to learn about all of them. And so I think there’s value […] having had an encounter, and having […] questions that are still lingering about a patient and having a space to like talk about those. - Participant 11

I believe in the power of the debrief. […] I think that it’s most effective when you learn right after a certain event or a patient encounter. That’s when our […] memories [are] most strong, and will make those associations. And so, if this is something that our faculty also value, and they’ve done plenty of debriefs after they’ve seen a particularly exciting medical conundrum, […] they can do a debrief on a particularly complicated interaction with a patient whether it’s culturally or whether it’s something else, and how we can improve that. - Participant 10

Implementation: Methods of implementation included short written reflections assigned several times a semester, as well as reflection sessions hosted by clinical mentors (ie, student advisors or clerkship directors). Educators agreed that reflection spaces were essential in effective cultural humility curricula. Many noted that the premise of cultural humility suggests that students will learn from encounters with patients from different backgrounds. Thus, guided reflection spaces are necessary for students to effectively process these encounters and gain insight for future patient interactions. Some educators noted that reflection spaces were already a significant part of their curriculum.

While reflection spaces are not an intervention specific to AANHPI-specific patient populations, educators and students both noted important applications for patients and providers who identify as AANHPI. Several educators noted the importance of reflection spaces for students to navigate current events that disproportionately affect AANHPI populations, such as the COVID-19 pandemic and the subsequent rise of anti-Asian violence.

Community-led workshops

Intervention: Students and educators both noted a dearth of engagement with AANHPI communities, leading to knowledge gaps in medical education curricula. Students and educators identified a need to work directly with local communities to learn about their values and how providers can better work with them. Community-led workshops on mental health and sexual health in AANHPI communities were highly desired. Emblematic quotes from focus group participants include:

I think it would be helpful to have a specific workshop on building cross-cultural competency. We don’t address a lot of topics, such as the benefits of race-concordant relationships between patients and doctors, and how to gain the trust of a community that may feel that their culture is not being respected. - Participant 8

I love the idea of getting out of the hospital for clinical experiences, and it would be cool to have more context about the Baltimore population. […] Often, we don’t get any context about the place we are in other than stereotypes about certain behaviors, so getting contextualization about AAPI populations in the place we are would be helpful. - Participant 15

I think it would be valuable to have patients from the AAPI community come and talk about how they navigated their illnesses and treatments while also holding onto their cultural beliefs. The patient panels we have had so far have focused on the impact of illness on the patient’s life, which is important, but hearing about patients’ experiences of holding onto their beliefs during treatment and working with doctors would be insightful. - Participant 5

I think it will be really cool to have a discussion about Asian American health and mental health, sexual health, which I think is a really understudied area. - Participant 4

Implementation: Methods of implementation suggested by students and educators included hosting community-led workshops or panels on health topics impacting their communities, inviting community members to speak about their health conditions, connecting students with community-based clinics or enabling students to conduct community-based research. All institutions in this study had a community engagement strategy already existing in their curriculum, but all educators noted a need for increased community engagement. Given that many institutions already had some form of community-based engagement, educators noted that building on existing infrastructure would be more feasible than implementing entirely new interventions. Several respondents also suggested that community-led interventions were effective in highlighting subgroups under the AANHPI umbrella and disaggregating the AANHPI monolith. One respondent shared that workshops on mental health led by Hmong community members at their medical school had overwhelmingly positive feedback from student attendees.

Educators outlined certain difficulties with implementing and expanding community-led partnerships. Given the diversity of subgroups underneath the AANHPI umbrella, educators and students were cautious of highlighting experiences from a limited number of communities, due to the risk of representing specific AANHPI communities as representative of AANHPI patients broadly. AANHPI populations, once viewed as a homogenous monolith, are now recognised to contain diverse cultural subgroups within the AANHPI heading. Interventions should focus on disaggregating populations contained within the AANHPI term, rather than teaching specifically to one subgroup.¹³ Funding to compensate community members for their time and expertise was also frequently cited as a barrier. Moreover, community-led partnerships are challenging for institutions located in cities with a smaller AANHPI patient population, but students suggested leveraging virtual platforms such as Zoom. Students noted potential attendance bias, suggesting that students already interested in educating themselves on working with AANHPI patient populations would be the ones to participate in community-based programming.

Training on documenting patients’ language/cultural needs

Intervention: Students identified a lack of training on documenting patients’ language and cultural needs as a major curricular gap. While training on using interpreters was included in the curriculum at all represented institutions in this study, students—particularly those who had begun clinical training—noted that they felt underprepared to navigate the language and cultural needs of patients beyond using interpreters (ie, modifying physical examinations to respect cultural norms of modesty). Students articulated a desire for training on how to document patient needs in the electronic health record. Emblematic quotes from focus group participants include:

I do not know where to document [interpretation needs] nor do I know how to document [different levels of interpretation needs]…. just clarifying not only what their preferred language is, but their proficiency with English and their proficiency with their preferred language, I don’t know how to do that. - Participant 12

For Epic, I actually never thought about it, cause I’ve seen the languages that people speak written into the chart, but I have no idea how I put it in. - Participant 11

Implementation: All educators agreed that training on addressing patients’ language/cultural needs was an area of improvement in their institution’s curriculum. What curriculum did exist across the institutions focused primarily on how to use interpreters in the hospital system, but there was little to no training on what to do if an interpreter was unavailable for a specific language/dialect or how to document patients’ language/cultural needs effectively in the patient’s records. Several educators discussed that this training could help highlight the diversity of patients’ language/cultural needs under the AANHPI umbrella, particularly with regards to the various regional dialects within AANHPI populations. Students and educators also agreed that this intervention was particularly important for institutions located near diverse patient populations. Again, students and educators both noted that this intervention was not specific to AANHPI patient populations, but that the diversity of language and cultural needs contained under the AANHPI umbrella underscored the need for such an intervention.

Discussion

In this study, both educators and students noted that there was limited engagement of AANHPI community members and inclusion of health topics that disproportionately impacted AANHPI communities in current medical curricula, which aligned with previous research.^{10 13} Focus groups of students identified three areas of potential intervention to increase cultural humility training and improve care for AANHPI populations: reflection spaces, community engagement and clinical training on documenting patients’ cultural/language needs. Educators noted the importance of reflection spaces, particularly given current events, such as the rise in hate crimes, disproportionately harming AANHPI populations. They also cited the importance of increasing community engagement in their curricula, with community-led workshops on mental and sexual health as a potential avenue. Finally, educators agreed that training on documenting patient language and cultural needs was an important area of improvement and could provide an opportunity to highlight the diverse cultures under the AANHPI umbrella. While educators noted that implementing these interventions would require overcoming several barriers, such as financial barriers in compensating community representatives and time constraints in the curriculum, they agreed that implementation ultimately is feasible and beneficial for students.

Overall, these interventions provide opportunities to learn more nuanced aspects of AANHPI healthcare and practice skills and values that align with cultural humility frameworks broadly applicable to all patient populations. This mirrors the nationwide trend towards adopting cultural humility rather than cultural competency frameworks.⁸ However, despite a broader shift in medical education towards a cultural humility paradigm, many students expressed that they were unaware of cultural humility or its difference from cultural competency, suggesting that further work needs to be done on communicating this shift in medical education to students.⁸ AANHPI populations are uniquely suited to cultural humility curricular frameworks, as the diversity of the ‘AANHPI’ patient experience, as noted by both educators and students in our study, highlights the importance of disaggregation in discussions of patient experiences and patient backgrounds. As institutions shift away from cultural competency frameworks that were prescriptive and oftentimes monolithic in their discussion of patient populations and towards cultural humility frameworks that emphasise patient diversity and universal skills in engaging with patients from different backgrounds, AANHPI patient populations in curricula can be used to highlight differences between cultural competency and cultural humility to students.¹⁴ The interventions proposed in this study go beyond including AANHPI patient experiences in medical education. They also demonstrate feasible strategies for cultural humility frameworks to be incorporated effectively into medical school curriculum using AANHPI patient populations as an example, given the historical struggle of these populations to disaggregate their diverse experiences.¹⁴

Finally, both medical educators and students noted that while individual interventions are important, a broader cultural shift is necessary to encourage sustainable and long-lasting change. The interventions proposed provide proactive and interactive methods to not only incorporate cultural humility training into medical curricula but also increase interactions among students and faculty to promote this needed cultural shift. Additionally, the incorporation of community voices as well as patient values could better prepare students to become physicians who provide human-centred care. The establishment of cultural humility practices among physicians best begins at trainee levels, which can improve how students, faculty, patients and communities interact and trust one another in navigating healthcare systems in the United States.

This study has several limitations. First, the study used purposive sampling of educators already involved in DEI initiatives and featured a small sample size. Furthermore, our student focus groups were conducted at a single institution, consisted primarily of students with an AANHPI background (13/15), and may not be representative of medical students nationally. Instead, focus groups conducted at JHUSOM served as a case study, with the goal of using the findings of this study in additional medical institutions. In addition, our study was limited by a small sample size. However, sampling was conducted until no new information was elicited when interviewing additional medical students or educators, giving confidence in the validity of our findings. Moreover, our approach was informed by previous research findings that saturation in qualitative studies can potentially be achieved with five interviews.¹⁵

Conclusion

The AANHPI community consists of diverse populations with distinct and overlapping cultural heritages. Cultural humility curriculum is an important tool that combats AANHPI health disparities while also highlighting the diversity within the AANHPI community. As AANHPI communities continue to grow in numbers, it is important that the next generation of clinicians serves this population in a culturally sensitive manner. In this study, we identified three student-sourced, medical educator-supported interventions to improve cultural humility-based training for treating AANHPI patients: reflection spaces, community engagement and clinical training on documenting cultural needs. These interventions could be used to not only increase awareness of issues impacting AANHPI communities but also potentially build clinician skills applicable to any diverse patient population.

Data availability statement

Data are available upon reasonable request.