Motivation of Asian Americans to Study Medicine: A Pilot Study

by

Ralitsa B. Akins, M.D., Ph.D.

Academic Assistant Professor

Associate Director of Residency Program

Department of Pediatrics

Texas Tech University Health Sciences Center

El Paso, Texas, USA

4800 Alberta Ave, TTUHSC, Department of Pediatrics, El Paso, TX 79905

Tel: (915) 545 7555 x 229 and (915) 892 1040

Fax: (915) 545 6976

Ralitsa.Akins@ttuhsc.edu

ralitsa_akins@yahoo.com

Abstract

This preliminary study lays the ground work in defining the possible motivational factors for Asian Americans to study medicine in the United States. The percentage of Asian American students in U.S. medical schools has been consistently higher than the percentage of Asian Americans in the U.S. general population and in undergraduate school programs. Extensive literature review revealed that this phenomenon has not been given the attention it deserves. Through semi-structured interviews, qualitative data were obtained from 10 medical students in a medical school in Texas to guide defining the dimensions of the issue and future research. The results of this pilot study indicated that major motivating factors for Asian Americans to study medicine include family and cultural emphasis on academic success, perception of obligation to respond to family needs and expectations, and desire to establish credentials in the host society via socially respected professional careers. The approach of servant leadership was introduced partially in response to the findings of the pilot study to promote professional values and leadership skills and counterbalance the motivation for money and prestige among medical students. The study findings are important in defining future research, healthcare policy and administrative decision-making in medical schools and healthcare organizations, especially in regard to service to the community.

Keywords: medical education, motivational factors, success in education, Asian Americans, socio-cultural background, servant leadership

Background

In the Background section, major trends in medical school population diversity are explored in regard to Asian American cultural values for success, Asian educational values and traditions, and relatedness to immigration laws fostering professional workforce immigration. This background exploration, presenting the diverse forces forming the environment for Asian American immigrants and their cultural roots, will help the understanding of the results of the pilot study on motivation of Asian Americans to study medicine.

Asian Americans in U.S. Medical Schools

The problem of diversity in U.S. medical schools has been longstanding. Thus far, more attention has been paid to number of admissions per race or ethnicity categories, than to the diversity of medical student cohorts compared to the diversity of the general population and the possible implications to serving patient populations. Traditionally, the numbers of Black and Hispanic medical students have been low, and these groups have been considered as “underrepresented” minorities. The percentage of Asian American students in U.S. medical schools has been notoriously and consistently higher than the percentage of Asian Americans in the general population and in undergraduate school populations. According to U.S. Census 2000, 3.6% of the total population of the United States and 2.7% of the Texas population is Asian American (Census 2000, Texas State Data Center Online). As seen on Table 1, 12% to 30% of the medical classes in Texas public medical schools for the period 2001-2005, consist of Asian American students (THECB, 2006). Therefore, Asian Americans cannot be considered an underrepresented minority in Texas medical schools, although they are a minority population.

Table 1: Percentage of Asian American Students (Total) in Public Medical Schools in Texas (Source: THECB, 2005 and private correspondence to THECB)

A similar trend is seen for the medical schools across the country over several decades. In a longitudinal study (1974-1999) of the trends in the applicant pool for U.S. medical schools, the number of minority applicants increased 45% over the 25-year period (Hall et al, 2001). Thernstrom (1997) noted that Asian Americans make up a strikingly large proportion of the students on most California campuses, comprising more than 33% of the University of California’s medical class for the academic year of 1996-1997. While in 1988 Asian American applicants represented 12% of the U.S. medical schools’ applicant pool, in 1999 they represented 20% of all applicants to medical schools in the U.S. This percentage has remained somewhat stable over the years.

According to the Association of American Medical Colleges, in 2005, 20% of the applicants and 20% of the matriculants in U.S. medical schools were Asian American (AAMC, 2005) (Table 2). Changes in the numbers of Asian American applicants are considered one of the major driving forces for increase in the medical school applicant pool (Hall et al, 2001).

Table 2: Asian American Applicants and Matriculants, US Medical Schools (Source: AAMC, 2005)

Family Expectations in Cultures Valuing Education

Asians, as the third largest minority group in the U.S., represent over 30 distinct cultures and languages with major subgroups including Asian Indians, Chinese, Japanese, and Koreans. Nevertheless, Asian Americans typically have strong ties to the family and follow a hierarchical model proceeding from elder to younger and from male to female. Asian families traditionally put a great emphasis on education and continuous gathering of knowledge, and Asian American teenagers are strongly influenced by their families in career choices (Sandhu 1999; Harrison 1992; Salili & Hoosain 2003; Helweg & Helweg 1990).

These similarities across Asian American families are attributed to similarities in Asian cultures. Culture, as a major construct in individual and group behavior, constitutes of shared practices and shared mentalities. Culture is represented by child rearing, educational system, language and religious beliefs. Switching between different cultures is possible in response to social cues (Salili & Hoosain 2003).

In many Asian cultures, students are not viewed as autonomous; rather, the students should live up to their role of being “students.” Thus, students are expected to adjust to the school environment and maintain high achievement level, improve their skills, and not embarrass their families. Students are encouraged to invest effort, be self-critical and pay attention to their weaknesses. Students are pressured to perform well academically and “fit in” their ethnic standard for success. The school success of Asian Americans is attributed to the high value their cultures place on education (Salili & Hoosain 2003; Walker-Moffat 1995). This is congruent with the middle class values in America. The family centered nature of Asian cultures is perceived to be the key to academic success.

Many Asian American students are under a tremendous pressure to achieve in school, and equate the success on a test with success in their future. Educational achievement is part of the family pride and honor, and children work hard to meet the expectations of their families. Meeting teachers’ expectations for school achievement, and family expectations for obedience and respectfulness, confer a high status to the individuals and their families. However, members of the same ethnic group may show a wide variety of levels of achievement (Salili & Hoosain 2003; Walker-Moffat 1995).

Respect to family, achievement orientation and sense of duty and obligation were recognized by Kwan (1999) as some of the most important values for Asian Americans. The family values of most families from Eastern Asia (Taiwan, Korea, China) are shaped by the Confucian tradition where hierarchy is the predominant feature and adherence to basic relationships keeps people in their places. For example, Chinese and Japanese families rarely applied for the social welfare system in the U.S., because most of the needs were met with broad family support. Furthermore, Confucianism places a heavy emphasis on education as a means of progress; thus, many Asian Americans have attached high priority to education, consistent with the Confucian value system (Harrison 1992).

Similarly, the group is the major unit for consideration in the Asian Indian cultural system. Family is crucial economically and emotionally. The “honor” of the family is passed to the eldest son, who is expected to care for his parents. An undergraduate degree from England and a graduate degree from the U.S. are looked upon as prestigious and providing success in the Indian society. Over half of the faculty members in prestigious Indian universities have received their degrees in either Britain or U.S. An Indian immigrant that has not succeeded in the “new world” would not dare go back to India for fear of being thought as a failure from friends and family that have initially supported the venture. Failure is not an option for most Indian immigrants. Thus, Indian students strive to attain their educational goal at any price (Salili & Hoosain 2003; Helweg 1990; Walker-Moffat 1995).

The success of Asian Americans in the United States is related to their pro-work, pro-education, pro-merit cultural values, and family expectations for success in education (Gibson 2000). The concept of “immigrant rigor” attributes the incentive for high academic achievement to knowledge of family history of being a powerful family in the country of origin, or to the high expectations associated with the beginning of a “new life.” Tang and Fouad (1999) proposed a model of career development of Asian Americans, suggesting that the traditional paths to career choices for Asian Americans are strongly related to their family background, and family expectations and values, such as honor for parents, collectivism, conformity, and deference to authority.

The Contribution of Immigration Legislature

Only a few months after ratification of the Constitution, the Congress limited naturalization to “any alien, being a free White person.” Federal law restricted immigration to the United States on the basis of race for nearly one hundred years: from the Chinese exclusion laws of the 1880s until the end of National Origin quotas in 1965. In 1882 the Congress passed the Chinese Exclusion Act, and in 1917 an Asiatic Barred Zone was created to exclude all Asian immigrants. In 1921, a temporary quota system was established to confine immigration as much as possible to Western and Northern European individuals, making this bar permanent in the National Origins Act of 1924. Until 1940 the automatic acquisition of citizenship by virtue of birth was tied to race. Immigration disputes whether the definition of “White” refers to race or color were solved in courts. Since people from North Africa, Europe, Persia, India, Western Asia and Polynesia were considered to be Caucasian, i.e. White, courts decided whether the skin color of the applicant for immigration was indeed “White” (Haney-Lopez 1996).

The Chinese Exclusion Act of 1882, the 1922 Cable Act and the 1924 National Origins Act limited immigration from Asia and forbade women from China, India, Japan and Korea to enter the United States even as wives of U.S. citizens. Immigration of Asian spouses and children of U.S. servicemen was later permitted under the 1945 War Brides Act. The 1965 Immigration Act abolished the national origin quotas and Asian immigrants were allowed to enter the country under the provisions of “necessary skills” or for “family reunification” (Walker-Moffat 1995). The 1965 Amendments to the Immigration and Naturalization Act of 1952 emphasized “skilled labor” and “student” categories; therefore admitted immigrants possessed high educational levels and professional experience. The 1965 legislature allowed students to change their status to permanent residents if their studies were in the field of medicine, engineering or skilled professional occupations, needed for the economic growth of the country. Consequently, Asian immigrants who entered the U.S. after 1965, typically had a higher education in medicine, engineering or science (Sandhu 1999).

Methods

Definition of “Asian American”

For this pilot study, the U.S. Census racial/ethnic categories were used. The U.S. Census Bureau defines “Asian” as a person having origins in any of the original peoples of Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Study Population

The study target population consisted of 29 first and second year students self-identifying their race as “Asian.” The study sample consisted of 10 first year (M1) and second year (M2) Asian American medical students, comprising about one-third of the Asian American students in first or second year for the studied school. The interviewee characteristics are presented on Table 3. Seven of the participants in this pilot study were of Asian Indian descent. Seven of the interviewees had an immediate family member who was a physician (mother, father or a sibling).

Table 3: Interviewees’ characteristics

Selection of Study Sample

The individuals for interview were chosen according to the criteria derived from the research objective. These individuals were to have two major characteristics: (1) medical students, and (2) having “Asian” descent/self-identifying themselves as being from the “Asian” race. After obtaining IRB approval and contacting the Student Affairs Office, e-mail invitations to participate in the study were sent to all 29 students who qualified for the study. Two students expressed their desire to participate in the study. These two individuals were used as index subjects for the following snowball technique for interviewee recruitment (Fink 2000, Faugier & Sargeant, 1997).

Snowball Technique for Interviewee Recruitment

Snowball sampling is method used in the social sciences and qualitative research to study sensitive topics, rare traits, hard-to-reach populations, networks and social relationships (Kaplan, Korf, & Sterk, 1987; Lopes, Rodrigues, & Sichieri, 1996; Faugier & Sargeant, 1997; Magnani et al., 2005). The method involves sample selection by referral chains among group of people with specific, insider knowledge on the topic on interest. Instead of deciding ahead of time who will be interviewed, one or more initially contacted, index subjects, refer the researcher to other subjects, based on the defined inclusion criteria for the study. The researcher actively develops and controls sample’s initiation and conclusion (Faugier & Sargeant, 1997). Medical student population is difficult to reach due to overwhelmingly busy student schedules, where devoting time for interview and related travel and accommodations may be perceived as undue burden. The snowball technique for interviewee recruitment proved successful in reaching the medical students and the group of students of Asian descent in particular.

Study Instrumentation

The semi-structured interview methodology was utilized. The interview questions are presented in Table 4. Each interview lasted approximately one hour.

Table 4: Questions for semi-structured interview

Data Analysis

The study protocol did not allow for interview taping; therefore, the researcher took very detailed notes during the time of the interviews. The interview notes were discussed with the respondents at the end of the interview for correctness and completeness of capturing their thoughts and responses, and as means for member check validation. The notes were later transcribed, usually within the day following the interview. Themes were identified from the transcribed text utilizing naturalistic inquiry, as described by Lincoln and Guba (1985), where data are categorized, patterns are identified and filled in, and member checks are used for validation. Using this methodology, major motivational themes were identified and discussed.

Decision to Limit Sample Size Due to Lack of New Motivation Themes

Similarities in the themes were noticed during the first three interviews, and the identified themes were confirmed and enriched by the rest of the interviews. After the third interview no new themes were identified, and a decision was made to stop interviewing after 10 interviews due to the lack of new emerging themes.

Ethics

The protocol for this study was approved by the Institutional Review Board, and all interviewees signed a consent form.

Study Limitations

This pilot study is limited to the information acquired from literature review and the expertise of the interviewees.

Results

Similar expressions were used by all interviewees to describe their beliefs, motivation, and experiences. Although Asian Americans are a diverse group, close similarities were observed in the understanding of role of family, education and society in all interviews.

Family and Cultural Emphasis on Academic Success

Parental advices about career choices are based on personal experiences in immigrants’ home-countries, on cultural beliefs and on understanding of the societal processes in the new environment. One of the respondents pointed out, “If I have to summarize … I would say that parents have expectations, and these expectations are founded on the situations and environments in which they grew up. The expectations of the parents aren’t always reasonable and may be leading to complete pressure on the child.” This pressure consists of putting a strong emphasis on academic success.

The Asian culture teaches that if you study hard you can succeed in society. When asked what makes the Asian Americans successful applicants to medical schools, a first-year student replied: “My explanation is, and I think it might be applied to all Asians, that we are raised in an environment that values education. This is a good, long-standing tradition. Most Asian families emphasize education and this might be the biggest reason for success. I think hard work is the biggest factor for success. I want to emphasize the longstanding Asian tradition to raise the children to be successful at school.” Another student confirmed: “For Asian Americans, there are commonalities in family expectations. This is a common thread amongst the Asian culture – educational emphasis and hard work in general. There is a lot of just expectation of serving the family.” All interviewees agreed that Asians consider it important to get a college degree. One respondent stated that his mother and relatives “really push for school. School is the answer to everything; they believe that medicine is the surest way to make money, have prestige and be an important member of the community. It is more of a cultural thing – parents stress education a lot.”

A common idea emerged across all interviews: one reason for the high percentage of Asians in medical schools is the parents’ ideal of academic success. Most Asian children are strongly encouraged by their parents to work very hard in school and pay a lot of attention to their academic success. “Do the best of what you can do” is a prevailing advice regarding success in school. To be successful in school is part of the understanding of what can make an immigrant successful in fulfillment of the American dream. As one respondent explained, “This is really because of the work ethics our parents carry from Asia. Asians are very focused on academics. Like my Dad – he wouldn’t understand me going out. He would like me to be ahead of everybody else in class, to be first, to be top of the class. I see every day my father – he worked very hard studying, and still is always reading and doing something about studying.” The success of Asian Americans in medical schools seems to be predictable on the basis of culture-supported orientation towards academic success and because admission criteria for medical schools still pay high attention to GPAs and MCAT scores.

Most respondents attributed their decision to study medicine to family tradition. As one respondent explained, “My choice was pretty logical. One of my parents is a doctor and growing up in that atmosphere – it did have a role in my decision. I was in fourth or fifth grade when I was already considering something. It’s a pretty big point of reflection. I came to the understanding that my early exposure to the profession, and my mother being a doctor helped my decision.” Early exposure to the profession and parental role modeling were considered as having a great impact on the decision to study medicine.

Obligation to Respond to Family Needs and Expectations

All interviewees emphasized the role of family as a primary motivating factor. Seven interviewees had a parent or a sibling, who were medical doctors. Three interviewees did not have an immediate family member who was a physician but, nevertheless, their families strongly urged them to study medicine.

Family influence is important also in another sense – one respondent called it “brain-washing”. Parental expectations for their children to become medical professionals were clearly communicated. Emphasizing the prestigious and humanistic character of the medical profession, repeatedly stating that “this is a good profession to go to” and explaining how proud they would be if their children became medical doctors, Asian American parents shaped their children’s decisions early in the childhood period. The parents would encourage their children’s decisions to study medicine, saying that “this is good for you – it’s prestigious, doctors are prestigious people,” “you can help people, get money, have instant gratification,” or “we grew up in poverty and succeeded by hard work.” Most of the interviewees “were already thinking about it” in intermediate school. One respondent stated, “My parents wanted me to go into medicine and shaped my mind,” while another described, “The only thing they talked about to me when I was little was ‘when you are a doctor’ – that’d stick in my head. I thought: “Oh, I’m gonna be a doctor!”

Nine of the interviewed Asian American medical students made a statement that they were directly influenced by their families in their decision to become a physician. Only one stated that her parents preferred an academic career rather than a career in clinical medicine because her father “realized how difficult it is to be a doctor.” Nevertheless, her parents definitely expected her to engage in graduate studies in the field of medicine.

All respondents pointed out “money and security in general” as important factors for consideration while making their career decision: “Parents want their children to be in financially stable fields. There will always be a need for doctors. We have lived here for twenty years now, but Dad is still conscious about money. He wanted me to go to a stable profession and for money not to be an issue. There is a lot of family influence.” Medicine is viewed as a “stable job” – an expression that was present in all of the interviews. Asian American parents want their children to have a good, stable job that makes a good living and is good from a long-term view.

The family members in Asian families are traditionally close. As an interviewee explained, “Dad pays for my education. In my culture, parents support kids through school and later, when parents retire, kids support them.” Another respondent said: “I made my decision partly because of the financial problem. You understand, the financial situation in my family was not that good. Even if I wanted to go and do something else, I would have to choose a good, stable job. I want to take care of my parents, when my parents retire.” Medicine has always been considered a good source of earnings. The interviewed students were clear about the fact that money was not the only concern: “Money is important to have a stable, good life and also for your children. In addition, you earn respect in society. Both are important – money, yes, and respect for you and your children.”

Two Choices: Medicine or Engineering

A specific trend that applied to the Indian Asian American interviewees was recognized. “Indian Americans become either doctors or engineers” – a first-year medical student stated as a well known fact. Three of the pilot study interviewees had their undergraduate degrees in engineering. Another respondent had considered a career in both medicine and engineering because his mother’s family had many medical doctors, and his father was an engineer. Due to cultural traditional understandings, the number of “successful career” choices appeared to be limited in Indian-Asian American families.

Culture-wise, in India medicine and engineering are considered “successful professions.” An interviewee explained, “In India there are two main things a guy can do or is supposed to do: medicine or engineering – for success, intellectual success. If you don’t go to these – forget it: forget the respect and money. In India, in order to be successful, the only two careers parents talk about are medicine and engineering. A lot of Indians give two choices to their children – either to be a medical doctor or an engineer.” Cultural experiences and beliefs mark the career choices of Indian-Asian American students, guided by their parents to choose medicine or engineering as respected and successful professions.

Desire to Establish Credentials in the Host Society

Gaining respect in society and contributing to the community proved to be important motivational factors for Asian Americans choosing a career in medicine. “I could be a lawyer,” said one of the interviewees, “but society doesn’t look upon lawyers with the respect it looks upon physicians.” Gaining prestige in society was emphasized by all respondents as one of their primary motivations to choose a career in medicine. This is how one of the interviewed students described his motivation, “In Asian culture, doctors are highly respected. Most Asian Americans like to go into the profession for the personal respect and respect in society. Prestige is the major factor. Prestige is very important. When you help people you gain respect and society would really respect you.” Another respondent emphasized, “We are all immigrants and want to be respected… You see, it is important to realize – this is a profession particularly recognized for earning respect. This is important to immigrant families.” Having a career in a respected field establishes immigrant families’ credentials in the American society.

Servant Leadership

The idea of choosing to serve first, and then lead, as a way of expanding services to individuals and populations, is known as the practical philosophy of servant leadership (Greenleaf 2002; Prosser 2002). Servant leadership is extremely valuable in the medical profession, where practitioners should make sure that other people’s needs and priorities are served (patient care) before attending to personal needs and priorities (Size 2006; Swearingen & Liberman, 2004; Wilson 1998).

Fellowship in Servant Leadership

One medical school in Texas, which has a unique Leadership in Medicine Program, has established a Fellowship in Servant Leadership in India. These pilot data were one of three stimuli for developing the Fellowship. Other stimuli included the history of involvement in India’s Swadhayaya movement by a distinguished university professor who teaches in the Leadership Program and the recognized need to expose students to role models of servant leadership to counterbalance the motivation for money and prestige among medical students in the United States.

The Leadership in Medicine Program is a four-year curriculum that inculcates professional values and servant leadership skills. Students may apply for Fellowship funding to travel to India for one month to observe and study forms of servant leadership that focus on development of human potential. The goal of the Fellowship is for the medical students to experience servant leadership among professionals in India and to return to the United States to infuse that spirit into the practice of medicine throughout their careers.

There are three structured forms of servant leadership, and the students may develop other experiences to submit for approval. The Swadhyaya movement is a major component of the Fellowship. Swadhyaya, which means in Sanskrit “self-study,” has a close resemblance to Gandhi’s Sarvodaya movement. There are five dimensions to Swadhyaya (Unterberger 1990):

1. Spiritual - awareness of indwelling divinity in every human being;

2. Psychological – uniting people to cooperate in enhancing quality of life;

3. Social – permeating the caste system to create dignity for all and changing social behavior such as thievery, gambling, child and wife abuse;

4. Economic – working together to create impersonal wealth to help the needy;

5. Political – villagers are brought together to discuss issues and participate in decision- making.

More than 100,000 villages in Southern India have been transformed through this quiet, but powerful self-study. Students are housed by Swadhyaya members who make provisions for the students to observe and participate in all five dimensions in villages. Many American-Indian families in the United States participate in Swadhyaya, and, thus, some of the Indian medical students have grown up with experiential knowledge of these servant leadership principles. The experience in India, however, provides them a more intense exposure to the principles and the practices of Swadhyaya.

Other components of the Fellowship include the “Sawa Rural” and “Vansda,” also in Southern India.

1. “Sawa Rural” began as a hospital, but now includes schools, community health projects with 200 field workers and about 200 villages. This organization provides health care to women and children and social services. The medical students can live within the compound, observe, and interview the workers.

2. “Vansda” provides a close-up of the inspiring work of one physician, who has trained married women in a number of villages to diagnose and treat common illnesses such as tuberculosis and cataracts, thus decreasing infant mortality in the respective areas by 60%. He has established a hospital where he and other physicians provide cataract surgery free of charge.

These living examples of servant leadership give students inspiration and concrete guidance about how they need to use their creativity in community service. Five medical students have completed the Fellowship to date.

Conclusions

The cosmopolitan American culture sets the standard for success for all individuals (including immigrants) whether or not this standard is perceived as desirable or attainable. When local, ethnic cultural models fit the middle-class standard of the cosmopolitan model, then the prediction is that this cultural group will be successful, educationally, and economically (Canniff 2001). The society in the United States has paid a costly toll to the combination of increased personal income and welfare program support. The elimination of poverty and famine divorced work from securing basic needs but also eliminated the need of education as a goal for progress. For families of Asian ancestry, the cultural tradition of valuing education is still strongly present, and is reflected by the parental emphasis on educational success and supporting children’s career choices in professional fields.

The study interviewees perceived that in medicine if an individual studies hard he/she could become a successful medical doctor, while for other professions, confidence and connections are required, and it becomes hard for immigrants to succeed in the American society. The first immigrants who came to the United States excelled in science and math, and worked hard to get scholarships or, otherwise, they could not afford good education. The greater majority of Asian American students in medical colleges have parents or siblings who are doctors or engineers. The immigration regulations fostered an immigrant community that was largely compounded of professionals. Since the first immigrants were predominantly professionals, they became role models for the next generation. The summary of the study findings about possible motivation factors for Asian Americans to study medicine are presented on Table 5.

Table 5: Summary of the study findings about possible motivation factors for Asian Americans to study medicine

As expressed by the respondents in this pilot study, major motivational factors for choosing the medical profession included respect and monetary rewards that are traditionally attached to the medical profession. While entry interviews to medical schools strongly consider the genuine desire of the applicant for community service, this theme was less emphasized in the pilot study interviews, where the respondents connected the desire for community service mainly to gaining respect in society. Therefore, introduction of focused education and practice of servant leadership for medical students may be beneficial in early professional value forming with orientation to service and empowering patients to partake in the management of their health.

The results of this pilot study indicate that family and cultural emphasis on academic success, coupled with perception of obligation to respond to family needs and desire to establish credentials in the host society, are most important in the decision to study medicine. These results are significant in several aspects:

1. Outlined need for future research of motivational factors - Additional research is needed to further explore the identified major motivational factors to study medicine:

A) Other ethnic and race groups, such as Whites, African Americans, Hispanics, etc., should be studies to identify commonalities in motivational factors;

B) A larger study, including several different locations nationwide (or, world-wide) is needed for further exploration of the pilot study findings;

C) A parallel study of motivational factors for students in engineering would shed an additional light on the perception that two major career choices are popular in families of Indian-Asian American descent.

2. Service to the community - Given the cultural make-up of medical classes, currently comprised of high percentages of Asian Americans, further research is needed to determine the preparedness of graduating physicians to adequately serve, from a cultural perspective, diverse populations with different ethnicity make-up.

3. Policy and administrative implications - The results from this pilot study and the results of the outlined future research agenda in particular are expected to have impact on:

A) Criteria for medical schools graduation and workforce development decisions in healthcare organizations in respect to cultural sensitivity training;

B) Curriculum renovation, e.g., community service in culturally diverse environments;

C) Administrative decision-making, e.g., identifying workforce development needs with culture and community applications.

Research in the outlined areas of interest will help identify and define the needs in leadership and community service education for the medical doctors of the future which would be expected to be culturally competent and ready to serve communities with ever growing diversity.

Acknowledgements

The author would like to thank Janine Edwards, Ph.D., professor of Humanities in Medicine and former co-director of the Leadership in Medicine Program at Texas A&M University System Health Science Center College of Medicine for her contribution to this paper.

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