Observational study of effect of ESFT approach on cross culture competency teaching for young PGY physicians

Abstract

Background

Globalization and the increasing influx of new immigrants have created multicultural demands in healthcare, emphasizing the need for enhanced cross-cultural competency among medical professionals. This study aimed to evaluate the impact of a cross-cultural competency course (4 C), designed using the ESFT model, on young physicians’ cultural sensitivity and related competencies in the setting of Taiwan’s healthcare system.

Methods

A mixed-methods approach was employed, integrating both quantitative and qualitative methodologies to assess the course’s outcome. Quantitative evaluations involved pre- and post-test measurements using standardized scales to assess cultural care competency, multicultural perceptions, and multicultural competency. Qualitative data were collected through focus group interviews, supplemented by experiential and reflective learning methods integrated into the course design.

Results

The findings demonstrated significant improvements in cross-cultural competency among young physicians, as evidenced by notable increases in post-test scores across cultural sensitivity, multicultural perceptions, and multicultural competency. These improvements were particularly pronounced among those with more than two years of clinical experience, suggesting that learners’ professional experience and gender influence the outcome of cross-cultural education.

Conclusion

This study highlights the value of cross-cultural courses in enhancing young physicians’ competencies. It underscores the innovative teaching by the ESFT model to accommodate learners from diverse backgrounds and equip medical professionals to meet the challenges of multicultural healthcare environments.

Background

With the rapid development of globalization, international mobility has become increasingly frequent, leading to more intensive cross-cultural contact and exchange. As an essential region under the influence of globalization, Taiwan has seen a continuous rise in the number of new immigrants, individuals who have recently moved to Taiwan from other countries, gradually becoming the second-largest ethnic group in Taiwanese society. According to the National Immigration Agency of the Ministry of the Interior, from 1987 to 2021, the number of new immigrants in Taiwan exceeded 560,000, mainly from China, Vietnam, Indonesia, and other countries [1]. These immigrants from different cultural backgrounds have further contributed to Taiwan’s societal diversity, particularly within the healthcare system, where the needs of patients from diverse cultural backgrounds are significantly different. Healthcare providers are increasingly facing cross-cultural challenges, especially in patient care, doctor-patient communication, and treatment outcomes. According to Betancourt’s research, cross-cultural competency can be enhanced through organizational, structural, and clinical interventions to improve the quality of care in the context of cultural differences [2, 3]. Therefore, cultivating the cultural competency of healthcare professionals has become essential to meet the need of cross-cultural care and has gradually become one of the core issues in medical education.

Although the importance of cross-cultural competency has been widely recognized in academia and medical practice, there are still several gaps in current research and practice. Firstly, past medical education has predominantly focused on overcoming language barriers, primarily emphasizing establishing diagnoses and treatment [4]. This treatment-centered model often overlooks the more profound influence of cultural factors in doctor-patient communication, leading to superficial approaches to cross-cultural care in practice. Secondly, although international assessment tools for cultural competency, such as Campinha-Bacote’s IAPCC scale [5], exist, most of these tools are based on Western cultural contexts and may not implement without modification in setting of Taiwan’s healthcare. Further, current cross-cultural curricula are primarily one-directional lectures, lacking experiential learning mechanisms such as situational simulations, disrupting in development of medical students’ abilities to respond to cross-cultural challenges in real-life contexts. Given the “banking education” reducing learners’ acceptance and resulting in lower learning motivation [6], the cross-cultural learning model to promote students’ interaction and understanding of different cultures effectively become crucial to achieve effective outcome. Therefore, this study utilizes an innovative teaching model—the ESFT (Explanation, Social and Environmental Factors, Fears and Concerns, Therapeutic Contracting) model—to investigate the ESFT model and teaching cross-cultural competency for inexperienced young physicians.

The ESFT model has traditionally been used for educational communication between physicians and patients, with the advantages of being structured and personalized. This model emphasizes understanding the patient’s cultural background, social and environmental factors, fears and concerns, and establishing a therapeutic contract. This approach enhances communication efficiency between doctors and patients, promoting trust and cooperation in the doctor-patient relationship [7,8,9]. By systematically addressing patient needs, this model ensures that medical plans align more with patients’ cultural and personal circumstances, which helps improve treatment adherence and overall outcomes. The ESFT model emphasizes four core dimensions: Explanation, which focuses on understanding the patient’s or learner’s beliefs and understanding of the disease or problem; Social and Environmental Factors, which consider the impact of the patient’s or learner’s social background and living environment on their health and learning; Fears and Concerns, which identify the anxieties and worries in cross-cultural interactions; and Therapeutic Contracting, where feasible treatment or learning plans are jointly discussed and negotiated [10].

From the perspective of knowledge transfer in adult education, this study assumes that the relationship and communication between the physician and the patient is compared to that between the educator and the learner. Thus, applying the ESFT model to cultural competency teaching is assumed to be beneficial to promote the relationship between the educator and the learner.

Methods

Participants

The target population for this study consisted of medical students enrolled in professional quality courses, encompassing both undergraduate medical students and those in postgraduate medical programs. Eligibility criteria required participants to have completed at least one semester of professional quality courses, regardless of whether they passed or failed the course by the end of the semester, or even if they did not successfully complete the full semester. However, students who were actively enrolled in professional quality courses but withdrew from the program or dropped out before completing the semester were excluded. This exclusion criterion ensured that only students with consistent engagement in the courses were included in the analysis.

The study was conducted at Kaohsiung Chang Gung Memorial Hospital between 2022 and 2023. Participants were recruited using a convenience sampling method. All participants were fully informed about the study’s objectives, ethical guidelines, voluntary participation, and the intended use of their data. Written informed consent was obtained through a consent-to-participate document.

A mixed-methods approach was employed, integrating both quantitative and qualitative methodologies. Data collection included pre- and post-course assessments. Anonymous questionnaires, taking approximately 15–20 min to complete, were distributed to Postgraduate Year (PGY) participants who provided verbal informed consent prior to participation.

Data collection included pre-tests at course enrollment, post-tests two weeks after course completion, focus group interviews, and observational notes. All data were numerically coded and securely stored in encrypted files. Participation was voluntary, with a 50.6% completion rate. Confidentiality was maintained throughout the research process.

Course design

Pre-course meetings were held with cross-cultural communication experts to establish consensus on teaching strategies and course structure. The course incorporated visual aids, reflective videos, and scenario-based simulations to enhance cross-cultural communication skills.

The curriculum was structured around the four core dimensions of the ESFT model. Explanatory Model of Health and Illness: This component encourages students to reflect on and share their experiences regarding patient-provider interactions and the challenges of illness care, with the aim of enhancing their narrative and listening skills. Social and Environmental Factors: Students are prompted to critically analyze and provide key commentary and recommendations on the social context, healthcare settings, and the dynamics of patient-provider interactions. This process guides learners in clarifying and reflecting on the triangular relationship between the patient, the situation, and the healthcare system. Fears and Concerns: The focus is placed on identifying students’ fears and concerns in specific contexts, forming the central theme of their learning process. Therapeutic Contracting: Through experience sharing and group-based learning, students collaboratively develop solutions to challenging scenarios, thereby establishing key learning objectives. The teaching approach emphasized experiential learning, reflective practice, and participatory engagement. Post-course assessments included cross-cultural elements in objective structured clinical examination (OSCE) simulations to evaluate learning outcomes.

The course comprised a 1.5-hour session using a reflective OSCE model with three phases [11]. The first phase introduced learning objectives and the ESFT model. The second phase adapted traditional OSCE formats to an instructor-led approach, where instructors presented case scenarios and guided students through history-taking and patient education exercises. This approach optimized student participation within time constraints.

Quantitative data collection

The evaluation of cross-cultural competency teaching was structured into four key domains: cultural sensitivity (CS), cultural care competency (CCC), multicultural perceptions (MCP), and multicultural competency (MCC). Cultural sensitivity was assessed through a modified and translated Intercultural Sensitivity Scale (ISS) (Cronbach α = 0.884). Cultural care competency was measured using the CCC scale (Cronbach α = 0.902), while multicultural perceptions were evaluated using the MCP scale. The reliability of each domain determined by Cronbach’s α was more than 0.80, and the overall reliability was 0.94. Multicultural competency was evaluated using the MCC scale. Reliability analysis indicated high internal consistency (Cronbach’s α > 0.7). Both the MCP and MCC scales were initially developed and rigorously validated in Taiwan, showing strong psychometric properties regarding reliability and construct validity [10,11,12,13].

Qualitative data collection

Qualitative data were collected through focus group discussions (FGD) to gain in-depth insights into the participants’ learning experiences and perceptions. Trained interviewers led the research team’s talks in FGD. Discussion topics centered on the participants’ views regarding the course content, teaching methods, and perceived changes in cultural competency. The entire discussion was audio-recorded, transcribed verbatim, and later analyzed using thematic analysis.

Thematic analysis was conducted using a triangulation method to ensure the reliability and depth of the findings. A social science professor, two clinicians, and the corresponding author participated in the triangulation process. The analysis was performed manually through a document review of 188 lines of data without using specialized software. The thematic analysis identified four core themes for curriculum planning: (1) language and communication patterns, (2) values and routines, (3) religious beliefs, and (4) sociocultural influences.

Results

Quantitative analysis

Demographic information

This study collected data from a single medical center. During the study period, 79 individuals met the eligibility criteria for participation. However, due to the busy clinical workload of PGY (post-graduate year) trainees, only 40 were willing to participate in the study.

Among the participants in this study, 24 participants were male (60%), and 16 participants were female (40%), with an average age of 26.4 years. Most participants (60%) lived in southern Taiwan. Regarding religion, Taoism and non-religious belief were the most common, accounting for 19 participants (47.5%) and 15 participants (37.5%), respectively. The participants were primarily from the Kokkien ethnic group, with 28 individuals (70%). (Table 1)

Table 1 Descriptive statistics

Outcome of cross-cultural competency course

Pre- and post-test results showed significant differences in MCP and MCC. The post-test mean score on CCC was higher than the pre-test mean score (df = 39). Further, the overall post-test mean scores on MCP and MCC were higher than the pre-test mean scores, respectively, indicating a significant improvement following the course (Table 2).

Table 2 t test of cross-culture competency (N = 40)

According to the results of non-parametric statistical analysis, participants who resided in southern and central Taiwan before university exhibited significantly higher cultural care competency than those from northern Taiwan (Table 3). The Kruskal-Wallis test was employed due to small sample sizes, with several subgroups containing fewer than 10 observations, which did not meet the assumptions of normal distribution. Therefore, a non-parametric approach was deemed appropriate.

Table 3 Kruskal-Wallis test analysis on cultural competency assessment scales by pre-university residence (N = 40)

Influence of previous clinical experience and gender

The Kruskal-Wallis test was employed due to small sample sizes, with several subgroups containing fewer than 10 observations, which did not meet the assumptions of normal distribution. Therefore, a non-parametric approach was deemed appropriate. Participants with less than two years of clinical exposure showed no statistically significant improvements in CS, CCC, MCP, and MCC but were significant for participants with more than two years (Table 4).

Table 4 Kruskal-Wallis test on cross-cultural competency by clinical exposure time (N = 40)

The analysis of gender differences revealed no significant differences between pre-and post-test scores in CS, CCC, MCP and MCC among female participants but significant among male participants. (Table 5).

Table 5 Paired sample t test for multicultural competency among male (N = 24)

Discussion

Regarding cultivating cross-cultural competency, many educators have made an effort to do it. Cultivating cross-cultural competency in medical education has become an essential goal for educators seeking to prepare healthcare professionals for diverse patient populations. Cross-cultural competency enables physicians to provide equitable and effective care by understanding and addressing cultural differences in health beliefs, practices, and communication. Many medical educators have adopted strategies to incorporate this skill into training programs. These efforts often include integrating cultural diversity into curricula, using case-based learning, and facilitating experiential learning through patient-centered interactions. Betancourt emphasizes the importance of cultural competence in reducing healthcare disparities and improving patient outcomes [14]. Similarly, Dogra highlights the value of reflective practices, where medical students critically examine their biases and assumptions to engage more empathetically with patients from diverse backgrounds [15]. Experiential learning, such as clinical rotations in underserved or multicultural communities, further enhances students’ cultural awareness and adaptability [16]. Despite these advances, challenges remain, including limited time in already demanding curricula and inconsistent assessment methods for cross-cultural skills [17]. Nonetheless, fostering cross-cultural competency is critical in medical education, as it directly impacts patient satisfaction, trust, and overall quality of care in increasingly multicultural societies [18].

Banking education which was by criticized Freire may limit students’ critical thinking and problem-solving abilities [19]. Likewise, from perspective of adult education(ADED), the student-centered ESFT teaching model mincing patient-centered model in holistic healthcare model, emphasizes four core dimensions, including explanation, social and environmental factors, fears and concerns and therapeutic contracting [20]. Given the accessibility and accessibility of ESFT model in physician, -nursing relationship [10], these core values of ESFT model therefore would anticipatorily help medical educators to approach cultivating cross-cultural competence in young physicians, rather than banking education. Our findings revealed that the course the ESFT model significantly improved cross-cultural competency, with notable advancements observed among those with previous clinical experience and male participants. This study demonstrated that the ESFT model significantly improved cross-cultural competency, with greater advancements among participants with prior clinical experience and male participants. Clinical experience likely enhanced the ability to apply new skills [21], while gender-related differences in learning outcomes require further investigation. However, the limited sample size restrict the generalizability of these findings. Future research should explore these factors to confirm and expand upon the observed effects of the training.

Additionally, participants from middle and southern Taiwan exhibited more substantial improvements in cultural care competency compared to their peers from northern Taiwan [22, 23]. This regional difference may reflect variations in exposure to diverse cultural contexts or differences in healthcare delivery systems across regions.

The small sample size may limit our external validity. Future research should focus on assessment of the long-term effects and adjustment to improve 4 C teaching in medical education.

Conclusion

In summary, the study demonstrate the innovation and effectiveness of the ESFT model implementing 4 C. The results indicated significant improvements in cultural sensitivity, multicultural perceptions, multicultural competency, and cultural care competency. This student-centered approach offers a promising strategy for young physicians coping with patients from multicultural backgrounds. To our knowledge, this study was the first educational modality using the ESFT model in medical education.