The Model Minority Myth, Data Aggregation, and the Role of Medical Schools in Combating Anti-Asian Sentiment

Invited commentary: mental health services utilization disparities at the intersection of Asian ethnoracial identity and limited English proficiency

Nguyễn et al. (Am J Epidemiol. 2024;193(10):1343-1351) analyzed data from the US National Survey of Drug Use and Health (NSDUH) to show that Asian American Native Hawaiian/Pacific Islander (AANHPI) adults with limited English proficiency have substantially lower levels of mental health services utilization compared with White adults without limited English proficiency. The findings add to the growing literature using an intersectionality framework to understand health and health care disparities. We comment on the authors' notable examination of intersecting minoritized identities in mental health services utilization and the welcome emphasis on AANHPI health. We discuss the limitations of the NSDUH data, which are administered in English and Spanish only, and their limited ability to support analyses disaggregated by ethnoracial subgroups. We conclude by identifying gaps related to funding, training, and data disaggregation, and we highlight the role of mixed-methods approaches to advance our understanding of intersectionality and health disparities research. This article is part of a Special Collection on Mental Health.

Diverse by Design: A Comprehensive Guide to Inclusive Hiring for Emergency Medicine Faculty

INTRODUCTION

Emergency medicine (EM) lacks diversity, with only 9.9% of physicians from underrepresented backgrounds and women comprising 25% of the workforce. Diverse faculty enhance patient outcomes, innovation, and equitable education. This manuscript introduces the Brown Academic Emergency Medicine Faculty Inclusive Hiring Guide to address these disparities.

METHODS

Developed through literature review, stakeholder input, and pilot testing, the guide identifies best practices for equitable hiring. Key metrics such as patient outcomes and faculty retention informed the recommendations, refined through feedback from faculty and DEI experts.

RESULTS

The guide provides strategies to mitigate bias, standardize evaluations, and create inclusive job postings. It emphasizes training search committees, equitable interviews, and ongoing assessment of DEI metrics.

DISCUSSION

This resource offers practical, evidence-based solutions for advancing diversity in academic EM, addressing systemic barriers, and fostering equity. Continuous evaluation is critical for sustained progress.

CONCLUSION

The guide is a vital tool for creating inclusive academic EM environments, improving diversity, and enhancing patient care and educational outcomes.

Deconstructing the Monolith: An Educational Module for Understanding Disparities Within Asian American, Native Hawaiian, and Pacific Islander Populations

Introduction

Asian American, Native Hawaiian, and Pacific Islander (AANHPI) people represent one of the largest and most rapidly growing groups in the United States and are often aggregated as a homogeneous, rather than diverse, population in medical research and education. Currently, few educational interventions focus on the disaggregation of AANHPI patient populations and the improvement of knowledge about health disparities that affect AANHPI patients.

Methods

We developed, implemented, and facilitated a workshop for medical students to address AANHPI health disparities, adaptable for in-person and online formats. The 1-hour session involved a preworkshop evaluation; a PowerPoint presentation outlining the history of the Asian monolith bias, health disparities within AANHPI subgroups, and strategies for health care professionals and trainees to engage effectively with these communities; and a postworkshop evaluation. Pre- and postworkshop evaluations assessed participants' confidence and understanding of AANHPI health disparities. Additionally, the postworkshop evaluation gathered feedback on the presentation.

Results

Pre- and postworkshop evaluations revealed that this workshop, attended by 42 diverse participants over two sessions, significantly improved participants' understanding of the Asian monolith bias and AANHPI health care disparities (p < .05). Whether attending virtually or in person, participants reported notable improvements in their self-evaluated confidence in treating AANHPI patients.

Conclusion

The AANHPI patient population comprises a myriad of different cultures, historical contexts, and health needs. We present an educational module that is associated with significant improvement of knowledge about health disparities specific to this population, informing further efforts in cultural competence within medical education.

Asian Conscientization: Reflections on the Experiences of Asian Faculty in Academic Medicine

ISSUE

Asians have experienced a rise in racialized hate crimes due to the anti-Asian rhetoric that has accompanied the COVID-19 pandemic. However, there has been little acknowledgement of anti-Asian discrimination within the medical education community. While anti-Asian hate is not new or unfamiliar to us, four authors of Asian descent, it has given us an opportunity to reflect on how we have been complicit in and resistant to the larger racial narratives that circulate in our communities.

EVIDENCE

In this article, we provide a brief history of Asians in the Americas with a focus on anti-Asian hate. Next, while presenting stories from the perspective of Asian medical education researchers who were born/have settled in the U.S. and Canada, we take the opportunity to reflect on how our personal experiences have shaped our perceptions of ourselves, and the representations of Asians in the field of medicine.

IMPLICATIONS

We hope to create awareness about how stereotypes of success tied to Asians can be used as a tool of oppression creating strife between Black communities, Asian communities, and other people of color. There is a need to develop critical consciousness to address the issues of equity in academia and in clinical practice.

"Where are you really from?": a qualitative study of Asian American medical provider experiences

The COVID-19 pandemic highlighted how racially minoritized patients and clinicians have suffered racial discrimination. It also made visible the ways in which Asians across the globe experience racial hate and illuminated that the experiences of Asians in medicine are not often spotlighted. In the United States specifically, Asian Americans are not viewed as minoritized in medicine, yet their professional experiences are rarely highlighted. Informed by the discourses of the model minority, the forever foreigner, and ethnic lumping, we used Asian critical theory to explore how Asian American medical providers in Utah understand racial and ethnic identity and how these identities and experiences of racialization inform their professional identities. Using a case study approach, we identified and interviewed 23 physicians, physician assistants, and nurse practitioners (during spring 2022) who live in and practice medicine in Utah. Transcribed interviews were coded using reflective thematic analysis. Findings were organized into three themes: (1) feeling different, (2) experiences with discrimination, and (3) wrestling with the model minority myth. While Asian American medical providers experience not belonging, they also have the agency to disrupt discrimination and stereotypes. Asian American medical providers' racial and ethnic identities influence their professional interactions. Understanding the intersections of their social and professional identities are important to providing support for Asian medical providers, within the United States and beyond.

Understanding the factors related to how East and Southeast Asian immigrant youth and families access mental health and substance use services: A scoping review

The objective of the review is to identify factors related to how East and Southeast Asian immigrant youth aged 12-24 and their families access mental health and substance use (MHSU) services. To address how East and Southeast Asian youth and their families access mental health and substance use services, a scoping review was conducted to identify studies in these databases: PubMed, MEDLINE (Ovid), EMBASE (Ovid), PsychINFO, CINAHL, and Sociology Collection. Qualitative content analysis was used to deductively identify themes and was guided by Bronfenbrenner's Ecological Systems Theory, the process-person-context-time (PPCT) model, and the five dimensions of care accessibility (approachability, acceptability, availability and accommodation, appropriateness, affordability). Seventy-three studies met the inclusion criteria. The dimensions of healthcare accessibility shaped the following themes: 1) Acceptability; 2) Appropriateness; 3) Approachability; 4) Availability and Accommodation. Bronfenbrenner's Ecological Systems Theory and the PPCT model informed the development of the following themes: 1) Immediate Environment/Proximal Processes (Familial Factors, Relationships with Peers; 2) Context (School-Based Services/Community Resources, Discrimination, Prevention, Virtual Care); 3) Person (Engagement in Services/Treatment/Research, Self-management); 4) Time (Immigration Status). The study suggests that there is a growing body of research (21 studies) focused on identifying acceptability factors, including Asian cultural values and the model minority stereotype impacting how East and Southeast Asian immigrant youth access MHSU services. This review also highlighted familial factors (16 studies), including family conflict, lack of MHSU literacy, reliance on family as support, and family-based interventions, as factors affecting how East and Southeast Asian immigrant youth access MHSU care. However, the study also highlighted a dearth of research examining how East and Southeast Asian youth with diverse identities access MHSU services. This review emphasizes the factors related to the access to MHSU services by East and Southeast Asian immigrant youth and families while providing insights that will improve cultural safety.

Exploring patterns of alcohol use and alcohol use disorder among Asian Americans with a finer lens

BACKGROUND

National survey data suggest Asian Americans (AA) are less likely to consume alcohol and develop AUD than Americans in other groups. However, it is common for AA to be born outside of the US and carry gene variants that alter alcohol metabolism, both of which can lead to lower levels of alcohol involvement. The current study examined differences in alcohol use and AUD between AA and other groups before and after controlling for birth location and gene variants.

DESIGN

Past year alcohol measures were examined from adults 18+ (N=22,848) in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III before and after controlling for birth location (inside or outside of the US) and gene variants (ALDH2*2 and ADH1B*2/ADH1B*3). Gender gaps in alcohol measures also were assessed.

RESULTS

Before adjustments, AA were less likely than White Americans to drink in the previous year (OR=0.50, 95% CI 0.41-0.62), binge (OR=0.68, 95% CI 0.52-0.88), engage in frequent heavy drinking (OR=0.55, 95% CI 0.42-0.73), and reach criteria for AUD (OR=0.71, 95% CI 0.53-0.94). After controlling for birth location and gene variants, AA remained less likely to drink in the past year (OR=0.54, 95% CI 0.41-0.70) but all other differences disappeared. Gender gaps were only observed for AA born outside of the US, highlighting the importance of experience rather than racial category per se.

CONCLUSIONS

Findings indicate that heterogeneity among AA leads to spurious generalizations regarding alcohol use and AUD and challenge the model minority myth.

Rates of Compliance in South Indian American Communities of Southern California Regarding Cancer Screening

BACKGROUND

Studies have shown lower rates of cancer screening and high mortality rates among all Asian Americans than among non-Hispanic White populations. However, most of these studies often confound diverse Asian American subgroups with limited data on cancer screening for Indian Americans, with this group being particularly interesting because of their counterintuitive socioeconomic status. For this reason, the objective of this study is to evaluate knowledge of the United States Preventive Services Task Force (USPSTF) cancer screening guidelines and compliance among South Indian Americans residing in Southern California.

METHODS

This was a cross-sectional study gathering community responses through an electronic survey. The survey reports knowledge of USPSTF screening guidelines and participant compliance rates. Rates were further compared to non-Hispanic White populations from official sources.

RESULTS

South Indian Americans residing in California had lower rates of compliance for colorectal, lung, and breast cancer screening when compared to that of non-Hispanic White populations in the same region, with the exception of cervical cancer screening rates.

CONCLUSION

Understanding the cultural characteristics of special populations, such as Indian Americans, can help communities adhere to more effective screening practices that can improve outcomes.

Daily Moderate-to-Vigorous Activity of Native Hawaiians and Pacific Islanders and Seven Asian Subgroups by Types of Activities, American Time Use Survey, 2010-2019

The study used the American Time Use Survey data from 2010 to 2019 to compare the daily moderate-to-vigorous activity of Native Hawaiians and Pacific Islanders (NHPI) and seven Asian ethnic subgroups. Adults aged 24 years and older were included. The study analyzed activities from sports and recreation, household activities, and all activities carried out during the day. Outcomes were determined by the completion of 30 min or more of moderate-to-vigorous activity and the type of activity carried out in the day. Significant ethnic differences were observed for sports and recreation but not for household activities and not for all activities carried out during the day. Of the ethnic populations, NHPI were the least active, and Asian Indians and Chinese were the most active. A majority achieved 30 min or more of moderate-to-vigorous activity during the day from all their activities. Physical activity from household activities exceeded physical activity from sports and recreation. The most physically active group was adults over the age of 65 years, perhaps reflecting more time to exercise or greater concerns about their health. For sports and recreation, exercising with someone doubled the minutes of moderate-to-vigorous activity. The results emphasize the importance of activities performed around the household in addition to sports and recreation and the benefit of exercising with someone. Ethnic populations may be receptive to interventions that emphasize activities they are performing in their daily lives.

Experiences with Racism Among Asian American Medical Students

Importance

Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students.

Objective

To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment.

Design, Setting, and Participants

This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years.

Main Outcomes and Measures

The medical school experiences of Asian American medical students.

Results

Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future.

Conclusions and Relevance

In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.

Superheroes

This framed quote hangs above my 5-year-old son's "costume corner" that overflows with capes, masks, and uncomfortable looking unitards. I am not sure that he truly understands the meaning of this iconic quote, although I am positive that he believes in the power of Spider-Man. Superhero films take place in epic settings under extraordinarily challenging circumstances. The best ones, at their heart, represent a grounded story with an astonishing level of humanity. Beyond the special effects and flashy cinematography, modern-day superheroes cope with the human experience and help viewers connect to the part of themselves that believes in redemption, potential, and a little bit of magic. Heroes have no shortage of traumatic experiences, although what sets them apart, and gives people hope, is the strength of their character that allows them to overcome. Perhaps less flashy but equally important is the fact that behind every superhero is an unwavering source of support and emotional fuel in the form of a caregiver, a mentor, and/or a true believer.

Professionalism and professional identity formation in dental students: Revisiting the professional role orientation inventory (PROI)

OBJECTIVE

Professionalism is a hallmark of health professions education. Professional identity formation is a growing field of exploration in medical education, and the dental literature is sparse on just how professional identity formation is developed and assessed within dental education.

METHODS

The validated professional role orientation inventory (PROI) was administered to 2nd year dental students during a spring semester ethics course. The PROI includes four 10-item scales representing four attitudinal factors: Authority, Responsibility, Agency, and Autonomy.

RESULTS

When compared to a historical sample of dental students in the early 1990s, dental students today scored significantly higher on Responsibility (p = 0.0309) and lower on the Agency factor (p = 0.0001). Authority scores in the current sample of dental students were significantly associated with age and race, with an increase in age associated with a decrease in Authority (p = 0.0504) and Caucasian respondents demonstrating significantly higher scores than Asian or Other races. Debt was associated with differences in Autonomy (p = 0.0683) and Agency (p = 0.0106), with those in the 100k-300k anticipated debt range demonstrating lower levels of both Autonomy and Agency. Race was marginally associated with Responsibility with those in the Other race category (Hispanic, Black/African American, Other/Multiracial) demonstrating higher levels than Caucasian (p = 0.0513).

CONCLUSION

Dental students' scores denote a continued commitment to others yet a feeling of less sense of control as a practicing professional. A redefining of professionalism to include social activism and advancing health equity is required given their altruism and commitment to others, which remains high.

Representation of Asian American Populations in Medical School Curricula

Importance

Despite being one of the fastest-growing populations in the US, the Asian American population is often misrepresented in and omitted from health research and policy debate. There is a current lack of understanding of how Asian American populations are portrayed in medical school curricula.

Objective

To assess how Asian American populations and their subgroups are represented in medical school curricula.

Design, Setting, and Participants

In this qualitative study, the content of 632 lectures from all 19 courses of the preclinical curriculum at a single US institution from the academic year 2020 to 2021 was analyzed to identify and characterize unique mentions of race and ethnicity as well as granular ethnicity. Among the 632 lectures, we identified 256 nonrepetitive, unique mentions of race and ethnicity or granular ethnicity. These unique mentions were coded and analyzed for emerging patterns of use.

Main Outcomes and Measures

Study outcomes included (1) the frequency of specific racial and ethnic categories mentioned in the curriculum, (2) the relative proportion of mentions of race and ethnicity that involved or included Asian American data by courses and context, and (3) key themes representing emerging patterns found from qualitative analysis of curriculum content for mentions of Asian American populations or lack thereof.

Results

Among the 632 lectures, 256 nonrepetitive mentions of race and ethnicity or granular ethnicity were identified; of these, Asian American populations and/or their subgroups were mentioned in 79 of the instances (30.9%). The most common terms used to denote Asian American populations were Asian, with 36 mentions (45.6%); followed by Japanese, with 10 mentions (12.7%); and Chinese, with 8 mentions (10.1%). Overall, there were 26 mentions (10.2%) of American Indian or Alaska Native populations, 12 mentions (4.7%) of Asian and Pacific Islander or Asian American and Pacific Islander populations, 67 mentions (26.2%) of Asian or Asian American populations, 143 mentions (55.9%) of Black or African American populations, 62 mentions (24.2%) of Hispanic or Latino populations, 4 mentions (1.6%) of Native Hawaiian or Pacific Islander populations, and 154 mentions (60.2%) of White populations. During the analysis of the curriculum for representation of Asian American populations, the following 5 key themes emerged from the data: (1) omission, (2) aggregation, (3) inconsistent categorization, (4) misidentification of granular ethnicity, and (5) association of race and ethnicity with disease.

Conclusions and Relevance

This qualitative study suggests that the curriculum from a single US medical school largely mirrors the inappropriate use of race and ethnicity found in published health literature and clinical guidelines. Solutions with long-term results will require collaboration among diverse groups of interest to adopt inclusive research programs and design. Such solutions could better equip students in combating race-based medicine and could promote community outreach programs built based on trust.

Prioritizing Asian Americans, Native Hawaiians, and Pacific Islanders in the U.S. Health Equity Agenda

Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations are growing rapidly in the United States, yet AANHPIs remain understudied, overlooked, and misunderstood. During the COVID-19 pandemic, themes from the tragic history of anti-Asian bias and marginalization have resurfaced in a surge of renewed bigotry and xenophobic violence against AANHPIs. In this commentary, the authors discuss the role of medical schools in combating anti-Asian sentiment as an important step toward achieving health equity. Based on their collective expertise in health disparities research, medical education, and policy, they offer suggestions about how to disrupt the pattern of invisibility and exclusion faced by AANHPI populations. They consider ways that representative data, leadership in medical education, research funding, national policies, and broad partnerships can help address AANHPI health disparities.