The Effectiveness of the "Early Clinical Exposure" Course Based on Narrative Medicine in Cultivating the Professional Qualities of Undergraduates in Clinical Medicine: A Mixed-Methods Study

The Effectiveness of the "Early Clinical Exposure" Course Based on Narrative Medicine in Cultivating the Professional Qualities of Undergraduates in Clinical Medicine: A Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effectiveness of the "Early Clinical Exposure" Course Based on Narrative Medicine in Cultivating the Professional Qualities of Undergraduates in Clinical Medicine: A Mixed-Methods Study Li Zhao, Cai Huijuan, Yang Xiaolin, Lin Jingsong, Cao Wenhua, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7729445/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Mar, 2026 Read the published version in BMC Medical Education → Version 1 posted 12 You are reading this latest preprint version Abstract Background Global medical education frameworks (WFME, ACGME) stress integrating early clinical exposure (ECE) and humanistic cultivation, but traditional ECE (including some Chinese models) prioritizes procedural familiarity over empathy/doctor‒patient communication, failing the "bopsychosocial" model. Narrative medicine (NM) fosters empathy but is rarely integrated into undergraduate ECE. In alignment with China’s 2022 China Undergraduate Medical Education Standards, this study tests an NM-integrated "Early Clinical Practice" course for clinical undergraduates. Methods The mixed-methods study included 600 2023 Southern Medical University clinical undergraduates. A 32-hour course (8 h theory: career planning, healthcare systems, NM; 24 h practice: hospital visits, holiday practice) was implemented. The data were obtained from prescourse (520 valid) and postcourse (546 valid) surveys, clinical skill assessments, and 582 reflective reports and were analyzed via SPSS 26.0 and thematic analysis. Results Postcourse, 84.25% had higher professional enthusiasm, 82.23% had gained preliminary clinical thinking, 71.79% had enhanced humanistic awareness, and 69.23% had applied NM. Clinical skill scores were high (empathy: 85.60 ± 5.98). Over 90% of the reflective reports noted career/humanistic gains. Conclusions The NM-integrated course effectively boosts undergraduates’ professional identity, clinical thinking, and humanistic literacy. Future optimization of NM practices and holiday arrangements is needed. Early Clinical exposure Narrative Medicine (NM) Clinical Medical Education Medical Professionalism Undergraduate Medical Students Background Globally, modern medical education reform has centered on overcoming the limitations of traditional knowledge-focused curricula, with authoritative frameworks explicitly emphasizing the integration of early clinical exposure and humanistic cultivation. For example, the World Federation for Medical Education (WFME) has listed "early clinical engagement" as a core requirement in its global basic medical education standards, urging medical schools worldwide to connect preclinical learning with clinical practice in the early stages of undergraduate training [ 1 ] . Similarly, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has incorporated "professionalism" and "interpersonal communication skills" into its core competency system, reflecting a global consensus on moving beyond pure technical skill training to develop patient-centered, humanistic medical professionals [ 2 ] . Early clinical exposure (ECE), defined as authentic interactions with clinical settings, patients, or healthcare teams during preclinical education, has become a widely adopted practice across international medical curricula to enhance students’ professional identity and clinical relevance. European medical schools have implemented ECE through community-based placements and supervised patient encounters, with studies confirming improved student engagement and understanding of clinical workflows [ 3 ] . In Asia, institutions in Japan and Singapore have also introduced ECE programs, although most evaluations focus solely on clinical skill acquisition rather than the development of humanistic qualities [ 4 ] . However, a universal challenge persists: traditional ECE models—either in international contexts or some Chinese programs—tend to adopt a one-way "hospital visit + process explanation" approach. This model prioritizes familiarity with clinical procedures but neglects the systematic cultivation of students’ empathy, doctor‒patient communication skills, and ethical reasoning, ultimately failing to meet the demands of the modern "bopsychosocial" medical model advocated by the World Health Organization (WHO) [ 5 ] . Narrative medicine (NM), pioneered to integrate medical humanities with clinical practice, guides learners to listen to, interpret, and honor patients’ disease narratives, thereby fostering empathy and narrative thinking—capabilities identified as essential for addressing patients’ psychological and social needs by global medical education bodies [ 6 ] . While NM has been applied in medical curricula across North America, Europe, and Australia, its use remains largely limited to postgraduate training or standalone humanities courses. Few international studies, and even fewer in the Chinese context, have systematically embedded NM into undergraduate ECE programs to evaluate its combined impact on key professional qualities such as career cognition, clinical reasoning, and humanistic literacy [ 7 ] . As noted in existing research on ECE effectiveness—including studies on Chinese medical education—there is a clear gap in the exploration of how humanities-integrated design can enhance ECE outcomes, and NM-related research rarely links theoretical teaching to early clinical exposure scenarios [ 8 ] . In line with global educational trends, China’s 2022 version of the China Undergraduate Medical Education Standards - Clinical Medicine Major explicitly mandates "early clinical, frequent clinical, repeated clinical" teaching philosophy and identifies humanistic literacy as a core training objective [ 9 ] . However, Chinese ECE programs still face the same challenge as their international counterparts: balancing clinical exposure with humanities cultivation. To address this gap, this study draws on both global ECE best practices and localized educational requirements to design an "Early Clinical Practice" course that systematically integrates NM into undergraduate ECE. By evaluating the course’s impact on clinical medicine undergraduates’ professional cognition, clinical thinking, and humanistic qualities, this research aims to provide empirical support for ECE teaching reform—offering a replicable model that aligns with global medical education goals while addressing the unmet need for humanities-integrated early clinical training in the Chinese context. Methods To explore the effectiveness of the "Early Clinical Practice" course integrated with the NM in cultivating the professional cognition, clinical thinking, and humanistic qualities of clinical medicine undergraduates.A mixed-methods study combining quantitative research (precourse and postcourse surveys, clinical skill simulation assessments) and qualitative research (analysis of student reflective reports, in-depth interviews with teachers and students). Setting The study was conducted at Southern Medical University and its affiliated hospitals (The Eighth Affiliated Hospital, Nanfang Hospital, Zhujiang Hospital) from September 2023 to June 2024. The EXE course was carried out in Eighth Affiliated hospitals, covering departments such as emergency departments, narrative sharing centers, health management centers, and medical research centers. Characteristics of the participants The research subjects were 600 undergraduate students of the 2023 clinical medicine major at Southern Medical University, including 3 classes (300 students) at the First Clinical Medical College (Nanfang Hospital) and 3 classes (300 students) at the Second Clinical Medical College (Zhujiang Hospital). The inclusion criteria were as follows: students who completed all course links (theoretical teaching + practical teaching), participated in precourse and postcourse surveys, and submitted valid reflective reports (word count ≥ 500 words, with practical experience and personal insights). The exclusion criteria were as follows: students who did not fully participate in the course, had missing survey data, or whose reflective reports were unqualified (insufficient word count, empty content). Finally, 582 students' reflective reports were included in the analysis, with an effective rate of 97.00%. The sample size was determined on the basis of the principle of "10–15 samples per variable" in quantitative research, and the number of research variables (such as professional enthusiasm, career awareness, and clinical thinking) was approximately 40, so a sample size of 600 was considered sufficient. Curriculum Design and Implementation This course was developed in line with the curriculum framework of ECE for undergraduate clinical medicine programs, running across three consecutive semesters—from the second half of the first academic year to the second half of the second academic year. It had a total of 32 instructional hours, was split into 8 hours of theoretical teaching and 24 hours of practical teaching, and was assigned 1 academic credit. The assessment adopted a pass/fail binary system, with formative assessment accounting for 80% (including performance in practical participation and skill training) and summative assessment accounting for 20% (based on students’ reflective reports). The course was organized and implemented by the Science and Education Department of the affiliated hospital, with teaching tasks jointly undertaken by functional departments (such as the Medical Administration Department and Nursing Department) and clinical teaching and research sections (including internal medicine, surgery, and medical imaging), ensuring the integration of theoretical knowledge and clinical practice throughout the teaching process. Theoretical Teaching (8 Class Hours) Subject Classification and Career Planning (2 Class Hours) This module systematically elaborates on the structure of medical academic training, covering undergraduate, postgraduate, and doctoral stages, as well as the core professional competencies required of clinical physicians—such as clinical skills, interpersonal communication skills, and humanistic literacy. The teaching was led by senior clinical teachers with more than 10 years of clinical and teaching experience, who adopted a “case-driven + interactive guidance” method. For example, they introduced the development history of internal medicine subspecialties (e.g., cardiology, gastroenterology) through the career paths of renowned physicians and guided students to fill out a “personal career inventory” on the basis of their interests (e.g., “interest in surgical operations” or “preference for chronic disease management”) and academic strengths (e.g., “excellent experimental skills” or “strong communication ability”). During the interaction, most students initially expressed vague career orientations (e.g., “want to be a good doctor”); after the module, 78% of the students could clearly name 1–2 target specialties (e.g., “considering neurology due to interest in brain science”) and raised questions about postgraduate training pathways (e.g., “what are the differences between clinical medicine master’s and professional master’s programs?”), reflecting a significant improvement in their career planning awareness. Healthcare Systems and Hospital Operations (2 Class Hours) The content of this module focused on introducing China’s three-tier healthcare service system and the organizational structure of general hospitals, including administrative departments, clinical departments, and medical technology support departments (such as the Medical Imaging Department and Clinical Laboratory Department). It also details key hospital systems such as medical quality control protocols and patient privacy protection regulations, aiming to deepen students’ basic understanding of the medical industry’s operational framework and clinical service processes. The teaching team included both hospital administrators (e.g., the director of the Medical Administration Department) and clinical department heads. They used “onsite mapping + scenario simulation” to enhance understanding: for example, they distributed the organizational structure diagram of the affiliated hospital and invited students to simulate the process of a patient with “acute myocardial infarction” being transferred from the emergency department to the cardiology ward, requiring students to identify the participating departments (emergency, imaging, cardiology, and pharmacy) and their collaborative roles. Students initially struggled to connect the functions of different departments (e.g., forgetting that the Clinical Laboratory Department needs to issue emergency blood test reports); after 3 rounds of simulation, more than 90% of the students could accurately describe the entire collaborative workflow, and some students proactively asked about “how to handle cross-departmental communication delays,” revealing a shift from “memorizing department functions” to “understanding system operation logic.” Narrative Medicine (4 Class Hours) Guided by Yang Xiaolin’s Chinese narrative medicine and medical professionalism [ 10 ] , this module integrates typical clinical cases—such as narratives of tumor patients’ diagnosis and treatment processes and cases of medical dispute mediation—to teach students the integrated application of narrative thinking and evidence-based thinking. The teaching was led by professors specializing in narrative medicine, who adopted a “storytelling + role-playing” approach. First, they shared the narrative of a breast cancer patient “from diagnosis anxiety to treatment adherence” (with the patient’s consent for anonymization), guiding students to identify the patient’s unmet psychological needs (e.g., fear of chemotherapy side effects, worry about family financial burden). Then, the students were divided into groups to simulate “doctor‒patient communication scenarios”: one student played a “patient with early lung cancer” (expressing concerns about “whether surgery will affect future work”), and another played a “clinician” who needed to use narrative skills to respond. During the simulation, most students initially focused on explaining medical knowledge (e.g., “surgery has a 90% cure rate”) and ignored emotional resonance; after the teacher’s guidance (e.g., “first acknowledge the patient’s worry: ‘I understand you’re concerned about work after surgery’”), more than 60% of the students could combine “empathy expression + information delivery” in the second round of role-playing. After class, many students mentioned in their short reflections that “I used to think doctors only need to be good at treating diseases; now, I know that listening to patients’ stories is also a kind of treatment.” Practical Teaching (24 Class Hours) Hospital visits (20 class hours) The students were divided into small groups of 5–6, each led by a clinical instructor with at least 5 years of clinical experience. The instructors received unified pretraining, including “student guidance norms” (e.g., prohibiting taking photos of patients without consent, maintaining a quiet attitude during ward rounds) and “key observation points” (e.g., guiding students to note the doctor’s body language during patient communication). The groups visited key hospital units such as: ①Emergency Department: Instructors first explained the “triage principle” (prioritizing severe cases) and then guided students to observe the rescue of a “patient with acute asthma.” During the observation, instructors asked targeted questions: “Why does the nurse first give oxygen instead of taking blood tests?” Students initially answered “because oxygen is more urgent”; the instructor further explained “this is based on the ‘ABC principle’ of emergency rescue (Airway, Breathing, Circulation),” helping students connect clinical practice with basic medical knowledge. After the observation, 85% of the students could list the 3 core steps of emergency triage.② Narrative Sharing Center: Instructors invited recovered patients to share their disease experiences (e.g., a diabetic patient’s “struggle with diet control”). Before sharing, instructors taught students “active listening skills” (e.g., maintaining eye contact, nodding to respond); after sharing, students were encouraged to ask follow-up questions (e.g., “What advice do you have for doctors communicating with diabetic patients?”). Most students initially hesitated to interact, but after the first student asked a question, others followed—with more than 70% of the students participating in the discussion—and some students recorded the patient’s advice in their notebooks (e.g., “Doctors should explain diet plans in simple terms, not just list taboos”). ③Medical imaging departments: Instructors demonstrated the operation process of a CT machine and explained “how to protect patients’ radiation safety” (e.g., using lead aprons for nonexamin parts). They then guided students to compare the CT images of a “normal lung” and a “pneumonia lung,” asking students to identify the differences. Students initially struggled to distinguish the “ground-glass opacity” in pneumonia images; after the instructor used a “cloud covering the sky” analogy, more than 90% of the students correctly pointed out the abnormal area. Each department visit lasted 2–3 hours, and the students were required to complete onsite observation notes. Instructors checked the notes daily and provided feedback (e.g., “You recorded the doctor’s ward round content in detail; next time you can add your own questions, such as ‘why this treatment plan was chosen’”). Holiday Practice (4 Class Hours) During holidays, students take part in three types of practical activities, with each activity supervised by a dedicated instructor (clinical nurses for ward volunteering, community health workers for science popularization): ① Outpatient guidance: Under the guidance of nurses, students assisted patients with self-service registration and provided department navigation. Instructors taught students “elderly friendly communication skills” in advance (e.g., speaking slowly, using dialects if necessary). For example, when an elderly patient could not operate the self-service machine due to poor eyesight, a student initially tried to explain the steps verbally but failed; after the instructor reminded “you can hold the patient’s hand to operate together,” the student successfully helped the patient complete registration. The student later wrote in the practice log: “I used to think guidance was just telling directions; now I know it’s about adapting to the patient’s needs.” ② Ward Nursing Volunteering: Students accompanied hospitalized patients to chat and help with basic daily care (e.g., helping bedridden patients turn over) under the supervision of nursing staff. Instructors emphasized “respecting patient privacy” (e.g., knocking before entering the ward, avoiding discussing the patient’s condition in public). One student mentioned in the log, “A grandma with a fractured leg was in a bad mood; I chatted with her about her grandchildren, and she smiled. The nurse told me that ‘accompanying is also a form of care’—this made me understand the importance of humanistic care.” ③ Community health education volunteering: Students delivered popular science lectures on common disease prevention (e.g., “how to prevent hypertension”) in local communities, with instructors reviewing the lecture content in advance and guiding students to use “everyday examples” (e.g., comparing blood pressure to “water pressure in a water pipe”). Initially, students used too many professional terms (e.g., “systolic blood pressure”); after the instructor’s revision, they changed it to “the top number in blood pressure, which represents the pressure when the heart beats,” making the lecture more accessible. After the activity, community residents gave positive feedback, with some asking for “more lectures on children’s health.” After the holiday, students needed to submit a written report summarizing their practical experiences and insights, along with a parallel medical record—a key exercise in narrative medicine that combines objective medical data with the patient’s subjective experience of illness. The instructors graded the reports on the basis of “depth of reflection” and “application of narrative skills” and held a postpractice sharing meeting where outstanding students shared their experiences (e.g., “how to use narrative thinking to comfort patients”), further promoting peer learning. Research Tools Survey Questionnaire A self-designed structured questionnaire was used, which was divided into precourse and postcourse versions.The pre-course (2024) and post-course (2025) questionnaires were self-developed based on the narrative medicine-based ECE course objectives, relevant validated scales [ 11 ] , and expert consultation (3 medical education, 2 narrative medicine experts—who suggested adding “no significant change” to Likert scales). They went through item generation, expert review (CVI < 0.8 items eliminated), pilot tests (50 undergraduates, Cronbach’s α: 0.78/0.82), and finalization. Precourse survey: This survey included 8 questions distributed 1 week before the course and focused on students' major choice motivations (interest in medicine, family influence, social status and income, etc.), professional enthusiasm (very high, above average, average, below average, very low), perceptions of learning difficulty, career intentions (clinical front line, medical research, medical education, etc.), and willingness to pursue further education [ 12 ] . A total of 520 valid questionnaires were collected, with an effective recovery rate of 86.67%. Postcourse survey: This survey included 18 questions distributed 1 week after the course, covering curriculum effectiveness evaluation (changes in professional enthusiasm, impact of each module on career awareness, establishment of clinical thinking), NM application assessment (understanding and application level, help in doctor‒patient relationships), changes in career planning (adjustment of career intentions, changes in willingness to pursue further education), and curriculum improvement suggestions [ 13 ] . A total of 546 valid questionnaires were collected, with an effective recovery rate of 91.00%. Student Learning Materials (Reflective Reports) According to the course requirements, students need to submit a reflective report of no less than 500 words, including practical experiences (details of hospital visits and holiday practice), changes in career perception (before and after the course), insights into humanistic literacy (understanding doctor‒patient communication, empathy, etc.), and the application of NMs (specific cases of applying NMs in practice), and attach at least 2 pictures related to the practice. The research team formulated a unified coding standard and coded the report content in five dimensions: "career cognition", "clinical thinking", "humanistic literacy", "NM application", and "course suggestions". Data collection and analysis Data collection The quantitative data were collected through an online questionnaire platform (Questionnaire Star), and the data were cleaned with Excel 2021 (to eliminate questionnaires with missing key information or obvious logical errors). Qualitative data: Collected through the course management system (students upload reflective reports online), the research team checked the completeness of the reports (word count, pictures, content integrity) before analysis. Data analysis For quantitative analysis, SPSS 26.0 software was used for descriptive statistical analysis. Count data (such as the proportion of students with improved professional enthusiasm) were expressed as n (%), and measurement data (such as clinical skill simulation assessment scores) were expressed as x ± s. Qualitative analysis: The thematic analysis method was used. First, two researchers independently read the reflective reports to familiarize themselves with the data; then, they extracted initial codes (such as "realizing the responsibility of doctors" and "learning to communicate with patients in plain language"); next, they merged similar codes into subthemes (such as "career cognition improvement" and "communication skill enhancement"); and finally, they summarized the subthemes into core themes (such as "the course promotes the improvement of students' professional quality"). When there was a disagreement in coding, a third researcher participated in the discussion to reach a consensus, ensuring that the interrater reliability exceeded 0.8. Results Basic situation of the research subjects In the postcourse survey, the distribution of student classes was as follows: 106 students (19.41%) in Class 1 of Grade 1, 90 students (16.48%) in Class 2 of Grade 1, 107 students (19.60%) in Class 3 of Grade 1, 66 students (12.09%) in Class 1 of Grade 2, 80 students (14.65%) in Class 2 of Grade 2, and 97 students (17.77%) in Class 3 of Grade 2. There were 320 males (58.61%) and 226 females (41.39%), which was roughly consistent with the gender ratio of clinical medicine majors. Among the 582 reflective reports included in the analysis, 538 (92.44%) met the word count requirement and had substantial content, and 44 (7.56%) had insufficient word counts but contained extractable valid information. Precourse Baseline Cognition of Students Major Choice Motivation A total of 249 students (47.88%) chose clinical medicine because of "strong interest in medicine", 157 students (30.19%) were influenced by "family or friends' recommendations", 81 students (15.58%) considered "social status and income", and 33 students (6.35%) had other reasons (such as "wanting to help others"). Professional Enthusiasm A total of 303 students (58.27%) had "above average" enthusiasm for their major, 130 students (25.00%) had "average" enthusiasm, 71 students (13.65%) had "very high" enthusiasm, and only 16 students (3.08%) had "below average" or "very low" enthusiasm. Career Orientation and Willingness to Pursue Further Education Before the course, 62.11% of the students tended to be "clinical frontline doctors", 28.46% considered "medical research", and the rest chose other directions (such as medical education and medical administration). With respect to the willingness to pursue further education, 59.23% of the students desired to pursue further education, 22.31% were undecided, and 18.46% had no intention to pursue further education. Course Effectiveness Evaluation Results Changes in Professional Enthusiasm and Career Perception After the course, 27.66% of the students had "significantly improved" professional enthusiasm, 56.59% had "somewhat improved", and only 2.19% (11 students with "somewhat decreased" enthusiasm and 1 student with "significantly decreased") had decreased enthusiasm. The impact of each course module on students' career awareness is shown in Table 1. "Healthcare systems and hospital operations" and "hospital visit practices" had the highest impact proportions (67.77% and 67.03%, respectively), followed by "subject classification and career planning" (57.14%), "NM theory and practice" accounted for 40.29%, and "holiday practice activities" had the lowest impact proportion (15.20%). In the reflective reports, 93.13% of the students (542 reports) mentioned positive changes in career perception. For example, one student wrote, "Witnessing the emergency rescue process in the emergency department and the communication between doctors and the families of brain-dead patients in neurosurgery, I deeply realized that the medical profession is not only about mastering professional technology but also about shouldering the responsibility of saving lives and accompanying patients through difficult times." Another student mentioned, "The visit to the health management center made me understand that medicine is not only about treating diseases but also about preventing diseases. It is also a kind of medical responsibility to help the subhealthy population build a health defense line." Table 1 Impact of Course Modules on Career Cognition (n = 546) Course Module Number of Choices Proportion (%) Healthcare systems and hospital operations 370 67.77 Hospital visit practice 366 67.03 Subject classification and career planning 312 57.14 Narrative Medicine theory and practice 220 40.29 Holiday practice activities 83 15.20 Other 1 0.18 Total (multiple choices allowed) 1352 - Note: The sample size was 546. Since some students selected multiple options, the total number of choices was greater than 546. Cultivation Effects of Clinical Thinking and Abilities A total of 82.23% of the students believed that the course helped establish preliminary clinical thinking, 27.47% of whom thought it was "very helpful", and 54.76% thought it was "somewhat helpful". The effects of the course on enhancing students' various levels of awareness and ability are shown in Table 2. "Humanistic care awareness" had the highest enhancement proportion (71.79%), followed by "doctor‒patient communication skills" (68.86%), "clinical thinking ability" (60.07%), "professional responsibility" (54.03%), and "team collaboration ability" (53.85%), while only 2.93% of the students thought that there was no significant change. In the reflective reports, 65.29% of the students (380 reports) recorded the process of establishing clinical thinking. For example, one student wrote after the internship in the Department of Respiratory and Critical Medicine: "In the morning case discussion, the attending doctor analyzed the patient's condition from multiple angles such as symptoms, medical history, and examination indicators, and formulated a personalized treatment plan. This made me realize that clinical thinking is not the mechanical application of textbook knowledge but rather the comprehensive analysis and judgment on the basis of the actual situation of patients." Another student mentioned, "When observing laparoscopic surgery, the chief surgeon predicted the possible variation of the bile duct in advance and made corresponding preparations. This let me know that clinical thinking also includes the prediction and response to potential risks." In addition, phrases such as "the importance of aseptic operation", "the rigor of medical record writing", and "the necessity of multidepartment collaboration" appeared many times in the reports, which further confirmed the effectiveness of the course in cultivating clinical ability. Table 2 Effect of the Course on Enhancing Students' Awareness and Ability (n = 546) Awareness/Ability Dimension Number of Choices Proportion (%) Humanistic care awareness 392 71.79 Doctor‒patient communication skills 376 68.86 Clinical thinking ability 328 60.07 Professional responsibility 295 54.03 Team collaboration ability 294 53.85 No significant change 16 2.93 Total 1379 - Note: Same as Table 1. Recognition of Practical Links and Assessment Methods A total of 86.26% of the students believed that practical links (hospital visits, holiday practices) were "very helpful" (32.05%) or "relatively helpful" (54.21%); 87.54% of the students recognized the assessment method of "formative assessment (80%) + summative assessment (20%)", of which 33.88% thought it was "very reasonable" and 53.66% thought it was "relatively reasonable", and only 2.57% (12 students thought it was "not very reasonable" and 2 students thought it was "very unreasonable") thought it needed adjustment. In the reflective reports, 88.66% of the students (516 reports) gave positive evaluations of practical links. For example, one student wrote after volunteering as an outpatient guide: "When helping elderly patients operate the self-service registration machine, I had to slow down my speech and repeat the operation steps patiently. This kind of communication experience cannot be learned from textbooks, and it made me understand the importance of adapting to the communication needs of different patients." Another student mentioned, "Participating in ward rounds in the obstetrics department allowed me to see how doctors, nurses, and midwives cooperate to ensure the safety of mothers and infants. Every detail in the collaboration reflects the responsibility for life." With respect to the assessment method, one student suggested in the report, "Writing a reflective report helps me sort out the gains and insights from the practice. I hope that in the future, periodic practice logs can be added to facilitate timely summary and improvement." Special assessment results of the narrative medicine Comprehension and Application Ability A total of 69.23% of the students could master the application of NM, of which 19.60% were "proficient in application" and 49.63% "understood and partially applied"; 25.27% "understood the basic concepts but had difficulty applying"; and only 5.49% (29 students "only understood the concept" and 1 student "still did not understand"). A total of 85.35% of the students believed that NM was "very helpful" (28.94%) or "relatively helpful" (56.41%) for understanding doctor–patient relationships. In the reflective reports, 62.37% of the students (363 reports) recorded specific cases of applying NM in practice. For example, one student wrote, "When the teaching doctor explained the condition to a cancer patient, he first handed the patient a glass of warm water to ease the patient's tension and then used the metaphor of 'weeds in the garden' to explain the growth of tumors. This 'empathy - explanation - confirmation' communication method is exactly what we learned in the NM class." Another student mentioned, "In the gastroenterology department, I tried to explain the meaning of 'elevated creatinine' to the patient in plain language, from the function of the kidneys to the possible reasons for the increase. The patient's expression changed from anxiety to understanding, which made me realize that NMs can build a trust bridge between doctors and patients." In addition, one student reflected: "Facing critically ill patients, I once did not know how to comfort them. Through learning NM, I understand that listening carefully to patients' concerns and accompanying them silently is also a kind of treatment." Future application intentions and improvement needs A total of 87.91% of the students would "certainly" (31.87%) or "probably" (56.04%) apply NM in future studies and work; 43.22% of the students thought that NM education should strengthen "practical application", 31.50% suggested increasing "case analysis", and 20.70% hoped to deepen "theoretical depth". In the reflective reports, 58.08% of the students (338 reports) proposed suggestions for NM teaching. For example, one student suggested, "I hope to increase NM workshops, set up simulated doctor‒patient communication scenarios, and let us practice the application of NM in real situations." Another student mentioned, "Writing parallel medical records can help me record patients' disease stories and personal feelings. It is suggested to increase such practical tasks in the course to improve the ability to apply NM." Changes in Career Planning Career Intention After the course, 88.28% of the students tended to engage in "clinical frontline work" after graduation, 40.66% considered "medical research" (some students chose both clinical work and research), 30.77% focused on "medical education", and only 6.41% indicated "not engaging in medical-related work". Willingness to Pursue Further Education A total of 75.09% of the students had an increased willingness to pursue further education, 31.32% "significantly increased" and 43.77% "somewhat increased"; 22.53% had "no change"; and only 2.38% (11 students "somewhat decreased" and 2 students "significantly decreased") had a decreased willingness. Adjustment of Career Planning A total of 58.79% of the students had "tentative changes" in their career planning (such as clarifying the direction of specialized disciplines), 36.63% "maintained the original plan", and only 4.21% "became more uncertain". In the reflective reports, 72.16% of the students (419 reports) mentioned adjustments in career planning. For example, one student wrote after the internship in the Department of Cardiovascular Medicine: "Seeing doctors race against time to rescue patients with myocardial infarction, I made up my mind to engage in cardiovascular clinical work in the future. I also realized that I need to improve my professional level through postgraduate study to better cope with complex clinical situations." Another student mentioned, "The health education activities in the obstetrics maternity school made me interested in medical education. I hope to engage in clinical work while carrying out medical popularization and education work to spread medical knowledge to more people." Discussion The integration of narrative medicine into ECE is in line with the needs of medical education reform This study revealed that after the course, 84.25% of the students had improved professional enthusiasm, and 82.23% had established preliminary clinical thinking. In the reflective reports, over 93% of the students mentioned the positive impact of the course on career awareness and humanistic literacy. This result is consistent with the "early clinical" education philosophy advocated by the "China Undergraduate Medical Education Standards". Traditional ECE courses usually focus on "process cognition and clinical skill training" [ 14 ] , whereas this course, through the "medical system theory + hospital visit practice" model, allows students to intuitively experience the "urgency of emergency rescue" and the "transmission of patient stories in the narrative sharing center" [ 15 ] . This "theory-scenario-experience" closed-loop design effectively connects basic medicine and clinical practice, enhances students' professional immersion and identity, which is consistent with Simmenroth et al.'s conclusion that "ECE can enhance medical students' professional identity" [ 13 ] . Notably, the integration of the NM module significantly improved students' humanistic literacy: 71.79% of the students had increased humanistic care awareness, and 62.37% of the students recorded NM application cases in their reflective reports. This result confirms Yang Xiaolin et al.'s view that NMs can effectively cultivate medical students' empathy through "patient perspective simulation" and "disease narrative analysis" [ 10 ] and compensate for the deficiency of traditional medical education, which focuses on technology and ignores humanity. For example, students frequently mentioned "explaining medical conditions in plain language" and "listening to patients' psychological needs" in their reports, which reflects that NM has effectively cultivated students' "holistic medical concept". The Differentiated Effects of Course Modules Provide Directions for Teaching Optimization The data on the impact of career cognition show that the impact proportions of "healthcare systems and hospital operations" (67.77%) and "hospital visit practice" (67.03%) are significantly greater than those of "NM" (40.29%), and 93.13% of the career cognition descriptions in students' reflective reports also focus on these two modules. This is related to the cognitive characteristics of lower-grade students: freshmen majoring in clinical medicine are in the "industry cognition enlightenment stage", and they need to establish a professional framework through macrosystem explanations and concrete scenario experiences. The in-depth application of NM requires more clinical practice accumulation [ 16 ] , so its impact on students' initial career cognition is relatively limited. In addition, the participation rate of "holiday practice activities" was relatively low (15.20%), and only 15% of the students mentioned holiday practices in their reports. This may be due to the conflict between practice time and students' holiday arrangements (such as make-up classes and family trips). In the future, the practice time and form should be optimized, such as by adopting an "online + offline" combined volunteer service model (online: popularizing medical knowledge through short videos; offline: participating in community health services on weekends), to improve students' participation. In the special assessment of the NM, 43.22% of the students suggested strengthening "practical application", and 58.08% of the students proposed similar needs in their reports (such as increasing simulated communication and parallel medical record writing). This reflects that the current NM teaching still focuses on "theoretical explanation + case analysis" and lacks practical operation links. Savitha et al. noted that practical NM teaching (such as allowing students to write patient disease narratives) can significantly improve students' application ability [ 17 ] . Therefore, in the future, modules such as "clinical narrative workshops" and "standardized patient-simulated communication" can be added to the course, and clinical teachers can guide students to apply NM to actual doctor‒patient communication to promote the transformation of narrative thinking into clinical practice ability. The Course highlights the guiding role of career planning and reflects the long-term value of medical education After the course, 88.28% of the students tended to engage in clinical frontline work, and 75.09% of the students had an increased willingness to pursue further education. In the reflective reports, 72.16% of the students mentioned adjustments in career planning. This shows that the course, through the progressive design of "department visit - career awareness - skill training", helps students clarify their career directions. For example, high-intensity clinical scenarios in the emergency department help students realize the importance of "solid professional knowledge and rapid decision-making ability", thus increasing their willingness to pursue further education to improve their professional level. NM cases also attract some students' attention to "medical education" and "medical research" (such as participating in patient narrative collection and sorting and being interested in medical humanities research), which reflects the course's guiding role in promoting the diversified development of students' careers. Research advantages and limitations Advantages Large Sample Size and High-Quality Data Ensure Result Reliability This study enrolled 600 undergraduates from two clinical medical colleges of Southern Medical University, covering students of different grades and genders. The sample size meets the principle of "10–15 samples per variable" for quantitative research (involving approximately 40 variables such as professional enthusiasm and clinical thinking). Eventually, 582 reflective reports were included in the analysis (with an effective rate of 97.00%), and 92.44% of these reports met the requirements of "≥500 words, including practical experiences and personal insights". This large sample size effectively reduces random errors, while high-quality primary data records the authentic experiences and cognitive changes of students, providing sufficient empirical support for the conclusions and significantly enhancing the representativeness and reliability of the results. Mixed Research Methods Avoid Limitations of Single Methods The study innovatively adopted a "quantitative + qualitative" mixed research method, which effectively compensates for the inherent defects of single research methods. This design aligns with the application advocacy of mixed methods in medical education research, where purely quantitative assessment is prone to "reductionism tendencies", while purely qualitative research has limitations in generalizability. In the quantitative dimension, pre-course and post-course comparative questionnaires (with effective recovery rates of 86.67%–91.00%) and clinical skill simulation assessments were used to systematically quantify changes in indicators such as students' professional enthusiasm and clinical thinking, with the empathy ability score reaching 85.60 ± 5.98, providing objective quantitative evidence for course effectiveness. In the qualitative dimension, thematic analysis was applied to code the reflective reports (with inter-rater reliability > 0.8), revealing in-depth cognitive changes such as the shift from "disease-centered cognition to person-centered care concept". This combination of "quantitative data verifying effect magnitude + qualitative data revealing internal mechanisms" forms a complete evidence chain, perfectly aligning with the core value of mixed methods in "balancing quantitative focus and retaining assessment authenticity", and avoiding the one-sidedness of single research methods. Innovative Course Design Fills Gaps in Medical Humanities Education This study is the first to systematically integrate narrative medicine into ECE course for undergraduate clinical medicine students, constructing a "theory-practice-reflection" trinity system. This design is not only in line with the requirements of "ECE and multiple clinical practices" in the National Standards for Undergraduate Medical Education Quality - Clinical Medicine Program (2022 Edition), but also directly responds to the value of integrating patient perspectives into early medical education. As confirmed by Dijk 's systematic review [ 18 ] , integrating patient perspectives into early medical education can significantly improve students' patient-centered awareness and communication skills. This study further transforms this concept into operable course practices through modules such as "narrative sharing center visits and parallel medical record writing". The data showed that 69.23% of students could apply narrative medicine, and 62.37% recorded application cases, effectively addressing the pain point of "disconnection between humanities education and clinical practice" in traditional medical education, and providing a replicable new path for the in-depth integration of medical humanities education and clinical practice. Limitations Sample Representativeness and Selection Bias First,the participants were all from one center (Southern Medical University), which is a high-level university with good cooperation between the university and the affiliated hospitals (such as the narrative sharing centers, well-trained instructors, etc.). This may not be the case in other medical colleges or vocational schools in the region, so the research results can hardly be generalized to the overall population of Chinese medical students. Secondly, there was no control group (such as students in the traditional ECE without NM), so we could not make causal inferences about the specific effect of NM. Thirdly, the inclusion criteria (such as completing all modules and submitting valid reflective reports) led to selection bias towards active students, and the positive effects may be overestimated due to the exclusion of some less active participants. Subjectivity in Data and Lack of Objective Validation The current study was primarily dependent on self-reported data, such as surveys and reflective reports, which are susceptible to social desirability bias. For instance, participants might overstate their perceived improvements to align with anticipated expectations. Although thematic analysis of reflective reports provides valuable insights, it is inherently subject to researchers' subjective interpretations, despite measures like interrater reliability. The absence of objective complementary data, such as standardized patient (SP) evaluations of communication skills or blinded clinician grading of case analyses, to corroborate self-reported outcomes, diminishes the validity of assertions regarding clinical thinking or NM application. Limited Generalizability to Diverse Contexts The findings of this study are limited to the context of Southern Medical University and the China’s Undergraduate Medical Education Standards (2022), which have significant differences from the accreditation frameworks used in other countries (such as the U.S. LCME, European directives). The specific model of NM implemented at this medical school (32-h, semester-based) is also different from the longitudinal patient-following model adopted by most Western medical schools, which has implications for cross-cultural transferability. Furthermore, by focusing on clinical medicine undergraduates, we did not include other health professions undergraduates (e.g., nursing, pharmacy), which further narrowed the generalisability of our findings. Directions for Future Research To address these limitations, future studies should adopt the following strategies:conduct multicenter studies across diverse Chinese medical schools (top-tier, regional, vocational) with a traditional ECE control group and randomized controlled trials (RCTs), while expanding eligibility to international samples and other health professions to improve representativeness and cross-context generalizability; establish 1-year and 3-year postcourse longitudinal tracking to measure sustained outcomes (including objective metrics like OSCE scores, teacher evaluations, and patient satisfaction, as well as long-term subjective data such as career choices and NM skill retention) and link data to administrative records (transcripts, residency matches) to assess professional impact,consistent with Ismail et al.’s [ 19 ] emphasis on balancing formative and summative assessment in medical education.; reduce subjectivity by supplementing self-reports with objective tools (e.g., standardized patient evaluations using validated scales like the Communication Assessment Tool, blinded clinician grading of clinical tasks) and using software (NVivo) for quantitative content analysis of reflective reports to minimize researcher bias; and develop adapted ECE-NM models for resource-limited settings (e.g., VR clinical simulations, online NM modules) [ 20 ], test cross-cultural applicability via international collaborations, and incorporate stakeholder perspectives (instructors, patients, educators) to evaluate feasibility and scalability. Conclusions Early clinical exposure (ECE) courses integrated with narrative medicine (NM) adopt a three-dimensional design of "theory - practice - humanity", which can effectively enhance the professional identity, clinical thinking, and humanistic literacy of clinical medicine undergraduates and clarify their career planning direction. The students' reflective reports and other learning materials further confirmed the practical value of the course: more than 90% of the students recorded positive changes in their career awareness and humanistic literacy during the course, and more than 60% reflected on the application of clinical thinking and NM. This course conforms to the development needs of modern medical education, which is "early clinical, more humanistic". In the future, it is necessary to further optimize the NM practical module (increase simulated communication and practical tasks) and adjust the holiday practice arrangement (adopt online and offline combinations) to provide a more replicable and promotable teaching model for the reform of ECE in medical education. Abbreviations NM Narrative Medicine ECE early clinical exposure SPSS Statistical Package for the Social Sciences Declarations Ethics Approval and Consent to Participate This study was approved by the Ethics Committee of The Eighth Affiliated Hospital, Southern Medical University, and was conducted in accordance with the Declaration of Helsinki. All the participating students were informed of the research purpose, content, and risks and signed written informed consent forms. Consent for Publication Not Applicable Availability of Data and Materials The datasets generated and/or analyzed during the current study are not publicly available due to the protection of students' personal privacy but are available from the corresponding author (Zheng Dayong) upon reasonable request. The student reflective reports used in the study are stored in the course management system of Southern Medical University and can be provided to relevant researchers after the approval of the school's teaching management department and the consent of the corresponding author are obtained. Competing Interests The authors declare that they have no competing interests. None of the authors have financial or nonfinancial relationships with any organizations that may be related to the subject matter of this study (such as pharmaceutical companies or medical education training institutions). Funding This study was supported by the Teaching Reform Project of Southern Medical University (No. JG2023028) and the Digital Experimental Teaching Demonstration Center for Clinical Comprehensive Competence Training of Medical Talents of Guangdong Province Education Department (No. 2024-30-8). The funder participated in the discussion of the course design plan but did not participate in the data collection, analysis, interpretation of results, writing of the paper, or the decision to submit the paper for publication. There is no other external funding for this study. Authors' contributions Li Zhao (LZ): Responsible for the design of the research plan, collection of survey data, and sorting of reflective reports. Cai Huijuan (CHJ): Participated in the implementation of the course, conducted in-depth interviews with students, and assisted in data analysis. Yang Xiaolin (YXL): Guided the design of the NM module, provided theoretical support for NM teaching, and revised the paper. Lin jingsong (LJS): Responsible for the organization of practical teaching (such as arranging hospital visits) and collected students' practice records. Cao Wenhua (CWH): Participated in the implementation of NM teaching. Zhang Peng (ZP): Participated in the clinical skill simulation assessment, scored students' performance, and provided professional clinical advice. Ren Jing (RJ): assisted in the coding and analysis of qualitative data (reflective reports) and identified typical cases. Zheng Dayong (ZDY): proposed the research topic, designed the overall framework of the study, guided the data analysis, wrote the first draft of the paper, and revised the final version. All the authors have read and approved the final manuscript. Acknowledgments We would like to thank all the participating students for their active cooperation in completing the surveys and writing reflective reports; thank the clinical teachers of the affiliated hospitals of Southern Medical University (including The Eighth Affiliated Hospital, Nanfang Hospital, and Second Clinical Medical College, Southern Medical University, especially Pro.Zheng Weiyang and Pro. Li Xiaodan ) for their support in the practical teaching of the course (such as guiding students' hospital visits and conducting clinical skill training); and thank the staff of the online questionnaire platform (Questionnaire Star) for their technical support in data collection. Authors' Information Li Zhao: Ph.D.,M.D.,Attending Physician, Associate Research Fellow, majoring in medical education, narrative medicine and clinical practice teaching, with research interests in the reform of ECE for medical students. Yang Xiaolin: Professor, Doctoral Supervisor, majoring in narrative medicine and medical humanities education, with research interests in the integration of narrative medicine into clinical medical education. Zheng Dayong: Ph.D.,M.D., Chief Physician, majoring in clinical medicine education and teaching management, with research interests in the cultivation of the professional qualities of medical students. References World Federation for Medical Education (WFME). WFME Global Standards for Quality Improvement of Basic Medical Education. Copenhagen: WFME; 2021. pp. 12–5. Accreditation Council for Graduate Medical Education (ACGME). ACGME Core Competencies. https://www.acgme.org/What-We-Do/Accreditation/Competencies . Accessed 10 Mar 2024. Simmenroth A, Harding A, Vallersnes OM, et al. Early clinical exposure in undergraduate medical education: A questionnaire survey of 30 European countries. Med Teach. 2023;45(4):426–32. Oshiro T, Suzuki S, Kagawa N, et al. Integration of early clinical exposure into curriculum enhances self-assessment of professional competencies in medical practice. BMC Med Educ. 2025;25(1):1139. https://doi.org/10.1186/s12909-025-07678-7 . World Health Organization (WHO). Person-Centered Care: A Guide for Health Care Providers. Geneva: WHO; 2020. pp. 28–32. Charon R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press; 2006. pp. 32–45. Savitha D, Iyengar A, Devarbhavi H, et al. Early clinical exposure through a vertical integration programme in physiology. Natl Med J India. 2018;31(5):296–300. Liu CI, Tang KP, Wang YC, Chiu CH. Impacts of early clinical exposure on undergraduate student professionalism—a qualitative study. BMC Med Educ. 2022;22(1):435. https://doi.org/10.1186/s12909-022-03505-5 . Ministry of Education, Working Committee for the Accreditation of Clinical Medicine Programs. China Undergraduate Medical Education Standards - Clinical Medicine Program. (2022 Edition). Beijing: Peking University Medical Press; 2022. pp. 18–20. Xiaolin Y. Wang Huafeng. The ability of medical narrative and career development. Guangzhou: Guangdong Science and Technology; 2023. pp. 89–102. Zhang Y, Liu M, et al. Development and validation of the Medical Student Professional Identity Scale. Chin J Med Educ. 2022;42(5):412–6. Li Z, Cai HJ, Yang XL, Cao WH, Lin JS. Early Clinical Practice Pre-Course Questionnaire [Unpublished raw data]. Southern Medical University. Appendix A.​; 2024. Li Z, Cai HJ, Yang XL, Cao WH, Lin JS. Early Clinical Practice Post-Course Questionnaire [Unpublished raw data]. Southern Medical University. Appendix B; 2025. Oshiro T, Suzuki S, Kagawa N, Ono H, Goto R, Furuta A, et al. Integration of early clinical exposure into curriculum enhances self-assessment of professional competencies in medical practice. BMC Med Educ. 2025;25(1):1139. https://doi.org/10.1186/s12909-025-07678-7 . Yang Xiaolin L, Xinjiang LZ. Narrative Hospital Management: From Lean Management to Value Cocreation. Guangzhou: Guangdong Science and Technology; 2024. Simmenroth A, Harding A, Vallersnes OM, et al. Early clinical exposure in undergraduate medical education: A questionnaire survey of 30 European countries. Med Teach. 2023;45(4):426–32. Savitha D, Iyengar A, Devarbhavi H, et al. Early clinical exposure through a vertical integration programme in physiology. Natl Med J India. 2018;31(5):296–300. Dijk SW, Duijzer EJ, Wienold M. Role of Active Patient Involvement in Undergraduate Medical Education: A Systematic Review[J]. BMJ Open. 2020;10(11):e037217. https://doi.org/10.1136/bmjopen-2020-037217 . Ismail OM, Elbarbary NM, Elsayed NM, et al. Theories and Practices in Learning and Assessment for Postgraduate Medical Education: A Review[J]. Cureus. 2024;16(3):e40127. https://doi.org/10.7759/cureus.40127 . Lee YJ, Kim JH, Park JY. Effects of early clinical exposure using virtual reality on learning: A text-mining analysis study[J]. J Educ Eval Health Prof. 2025;22:19. https://doi.org/10.3352/jeehp.2025.22.19 . Additional Declarations No competing interests reported. Supplementary Files PostCourseQuestionnaireforEarlyClinicalPractice.docx PreCourseQuestionnaireforEarlyClinicalPractice.docx TypicalStudentReflectiveReportswithPracticeImages.docx Cite Share Download PDF Status: Published Journal Publication published 05 Mar, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Reviews received at journal 02 Feb, 2026 Reviews received at journal 28 Jan, 2026 Reviewers agreed at journal 25 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviews received at journal 15 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers invited by journal 25 Nov, 2025 Editor invited by journal 24 Nov, 2025 Editor assigned by journal 14 Oct, 2025 Submission checks completed at journal 14 Oct, 2025 First submitted to journal 14 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7729445","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552200426,"identity":"e5523f9b-4f2a-4d1d-b5f6-bd41c143ca8d","order_by":0,"name":"Li Zhao","email":"","orcid":"","institution":"The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde)","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Zhao","suffix":""},{"id":552200427,"identity":"cfce49fd-6f95-4345-b3fd-4fc2a37227df","order_by":1,"name":"Cai Huijuan","email":"","orcid":"","institution":"The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde)","correspondingAuthor":false,"prefix":"","firstName":"Cai","middleName":"","lastName":"Huijuan","suffix":""},{"id":552200428,"identity":"10d6fa9f-a058-4cd8-9feb-b4cb6ffddfdb","order_by":2,"name":"Yang Xiaolin","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Xiaolin","suffix":""},{"id":552200429,"identity":"69a27f76-3d5c-417b-a673-95d288dd9345","order_by":3,"name":"Lin Jingsong","email":"","orcid":"","institution":"The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde)","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Jingsong","suffix":""},{"id":552200430,"identity":"1e9561b8-40fa-4fe9-ad72-7aaaa4cac856","order_by":4,"name":"Cao Wenhua","email":"","orcid":"","institution":"The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde)","correspondingAuthor":false,"prefix":"","firstName":"Cao","middleName":"","lastName":"Wenhua","suffix":""},{"id":552200431,"identity":"a614ae1f-7b55-4029-a54e-2ef09acb3f25","order_by":5,"name":"Zhang Peng","email":"","orcid":"","institution":"Southern Medical University Nanfang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Peng","suffix":""},{"id":552200432,"identity":"6fbe8fb5-a87c-4f2a-b1b5-ebbdd7508ea6","order_by":6,"name":"Ren Jing","email":"","orcid":"","institution":"Second Clinical Medical College, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ren","middleName":"","lastName":"Jing","suffix":""},{"id":552200433,"identity":"b8db6e2a-2b57-4d6d-bd64-62e7dc1a851f","order_by":7,"name":"Zheng Dayong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYDACCRDBxiAH4bGRoMWYdC2JDURrkZ/dfOzhl7LD6fOnnTFg+FB2mIF/dgN+LYxzjqUby5w7nLvhdo4B44xzhxkk7hzAr4VZIsdMWrINqEU6x4CZt+0wg4FEAn4tbBL530Ba0uVnA7X8JUYLj0QOm+THtsMJDECHMTMSo0VCIs1MmuFcuuGG22kFB3vOpfNI3CCgRX5G8jPJH2XW8vKzkzc+ADLk+GcQ0AICzDwMzWDGAZBLCasHAsYfDHVEKRwFo2AUjIIRCgAkyj/n97VSUwAAAABJRU5ErkJggg==","orcid":"","institution":"The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde)","correspondingAuthor":true,"prefix":"","firstName":"Zheng","middleName":"","lastName":"Dayong","suffix":""}],"badges":[],"createdAt":"2025-09-27 15:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7729445/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7729445/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-026-08885-6","type":"published","date":"2026-03-05T15:59:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97157569,"identity":"ea1a1db1-b632-4cd9-b8e2-7807edcbc92a","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52200,"visible":true,"origin":"","legend":"","description":"","filename":"cleanversionTheEffectivenessoftheEarlyClinicalexposureCourseBasedonNarrativeMedicineinCultivatingProfessionalQualitiesofUndergraduatesinClinicalMedicineAMixedMethodsStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/8211094b0af19966ec131269.docx"},{"id":97157568,"identity":"c3b19862-5fdb-45bc-8e17-7b89df770ff0","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14001,"visible":true,"origin":"","legend":"","description":"","filename":"ThetablesTheEffectivenessoftheEarlyClinicalexposureCourseBasedonNarrativeMedicineinCultivatingProfessionalQualitiesofUndergraduatesinClinicalMedicineAMixedMethodsStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/2d06eeb5cffcfbc50d4ea170.docx"},{"id":97248485,"identity":"f97fae1f-16d6-45ee-b592-3c69037029ff","added_by":"auto","created_at":"2025-12-02 13:00:30","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10752,"visible":true,"origin":"","legend":"","description":"","filename":"079f2652fdd84c2595d17927bd4fc350.json","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/aacef4827f9ef59e013e4949.json"},{"id":97157571,"identity":"4a7f5129-13d5-4497-bc6f-8591929989a8","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15398,"visible":true,"origin":"","legend":"","description":"","filename":"PostCourseQuestionnaireforEarlyClinicalPractice.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/b71ac218f4773f3f64228941.docx"},{"id":97157573,"identity":"9e5755eb-9377-4466-9a24-62f36989ecfd","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14691,"visible":true,"origin":"","legend":"","description":"","filename":"PreCourseQuestionnaireforEarlyClinicalPractice.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/4528e185c85691161d4a814f.docx"},{"id":97157579,"identity":"76f76ebc-5b2c-452e-862e-b2a06dd80a94","added_by":"auto","created_at":"2025-12-01 11:50:18","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40469059,"visible":true,"origin":"","legend":"","description":"","filename":"TypicalStudentReflectiveReportswithPracticeImages.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/7dc715d086b41c927f47c994.docx"},{"id":97157574,"identity":"ca43976b-6a26-44e8-93a1-38c004cd8621","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109492,"visible":true,"origin":"","legend":"","description":"","filename":"079f2652fdd84c2595d17927bd4fc3501enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/a5ea1dcdf8b811cc6b55a543.xml"},{"id":97157577,"identity":"9fe7dbe3-b263-4392-a6c3-20859ce482f8","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105104,"visible":true,"origin":"","legend":"","description":"","filename":"079f2652fdd84c2595d17927bd4fc3501structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/e5da762a7edba0de96d79c57.xml"},{"id":97157575,"identity":"c841290c-d871-4b8a-841d-5a7dd5a27e3d","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116191,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/43ce8df767d323ab57ec129d.html"},{"id":104252073,"identity":"9e1b0f3b-40a5-4c06-b0e4-6f542e1f35bc","added_by":"auto","created_at":"2026-03-09 16:17:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1372293,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/7f7d40d1-6ce6-4105-956d-8e7bc91f9e94.pdf"},{"id":97157570,"identity":"47163ce1-c716-4daa-a613-d2d80a4655c8","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15398,"visible":true,"origin":"","legend":"","description":"","filename":"PostCourseQuestionnaireforEarlyClinicalPractice.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/f2c72c2fb3eeae525475adeb.docx"},{"id":97157576,"identity":"ff3b1ef6-da3f-43c5-88af-5dacc691158b","added_by":"auto","created_at":"2025-12-01 11:50:17","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14691,"visible":true,"origin":"","legend":"","description":"","filename":"PreCourseQuestionnaireforEarlyClinicalPractice.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/e777a947c053b9113fbac2e0.docx"},{"id":97157580,"identity":"dd622d47-8d55-4cb9-94a4-930e622597ea","added_by":"auto","created_at":"2025-12-01 11:50:18","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":40469059,"visible":true,"origin":"","legend":"","description":"","filename":"TypicalStudentReflectiveReportswithPracticeImages.docx","url":"https://assets-eu.researchsquare.com/files/rs-7729445/v1/deb9b50eba3d5b319b9c9396.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effectiveness of the \"Early Clinical Exposure\" Course Based on Narrative Medicine in Cultivating the Professional Qualities of Undergraduates in Clinical Medicine: A Mixed-Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, modern medical education reform has centered on overcoming the limitations of traditional knowledge-focused curricula, with authoritative frameworks explicitly emphasizing the integration of early clinical exposure and humanistic cultivation. For example, the World Federation for Medical Education (WFME) has listed \"early clinical engagement\" as a core requirement in its global basic medical education standards, urging medical schools worldwide to connect preclinical learning with clinical practice in the early stages of undergraduate training \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Similarly, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has incorporated \"professionalism\" and \"interpersonal communication skills\" into its core competency system, reflecting a global consensus on moving beyond pure technical skill training to develop patient-centered, humanistic medical professionals \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEarly clinical exposure (ECE), defined as authentic interactions with clinical settings, patients, or healthcare teams during preclinical education, has become a widely adopted practice across international medical curricula to enhance students\u0026rsquo; professional identity and clinical relevance. European medical schools have implemented ECE through community-based placements and supervised patient encounters, with studies confirming improved student engagement and understanding of clinical workflows \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In Asia, institutions in Japan and Singapore have also introduced ECE programs, although most evaluations focus solely on clinical skill acquisition rather than the development of humanistic qualities \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, a universal challenge persists: traditional ECE models\u0026mdash;either in international contexts or some Chinese programs\u0026mdash;tend to adopt a one-way \"hospital visit\u0026thinsp;+\u0026thinsp;process explanation\" approach. This model prioritizes familiarity with clinical procedures but neglects the systematic cultivation of students\u0026rsquo; empathy, doctor‒patient communication skills, and ethical reasoning, ultimately failing to meet the demands of the modern \"bopsychosocial\" medical model advocated by the World Health Organization (WHO) \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eNarrative medicine (NM), pioneered to integrate medical humanities with clinical practice, guides learners to listen to, interpret, and honor patients\u0026rsquo; disease narratives, thereby fostering empathy and narrative thinking\u0026mdash;capabilities identified as essential for addressing patients\u0026rsquo; psychological and social needs by global medical education bodies \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. While NM has been applied in medical curricula across North America, Europe, and Australia, its use remains largely limited to postgraduate training or standalone humanities courses. Few international studies, and even fewer in the Chinese context, have systematically embedded NM into undergraduate ECE programs to evaluate its combined impact on key professional qualities such as career cognition, clinical reasoning, and humanistic literacy \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. As noted in existing research on ECE effectiveness\u0026mdash;including studies on Chinese medical education\u0026mdash;there is a clear gap in the exploration of how humanities-integrated design can enhance ECE outcomes, and NM-related research rarely links theoretical teaching to early clinical exposure scenarios \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn line with global educational trends, China\u0026rsquo;s 2022 version of the China Undergraduate Medical Education Standards - Clinical Medicine Major explicitly mandates \"early clinical, frequent clinical, repeated clinical\" teaching philosophy and identifies humanistic literacy as a core training objective \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. However, Chinese ECE programs still face the same challenge as their international counterparts: balancing clinical exposure with humanities cultivation. To address this gap, this study draws on both global ECE best practices and localized educational requirements to design an \"Early Clinical Practice\" course that systematically integrates NM into undergraduate ECE. By evaluating the course\u0026rsquo;s impact on clinical medicine undergraduates\u0026rsquo; professional cognition, clinical thinking, and humanistic qualities, this research aims to provide empirical support for ECE teaching reform\u0026mdash;offering a replicable model that aligns with global medical education goals while addressing the unmet need for humanities-integrated early clinical training in the Chinese context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo explore the effectiveness of the \"Early Clinical Practice\" course integrated with the NM in cultivating the professional cognition, clinical thinking, and humanistic qualities of clinical medicine undergraduates.A mixed-methods study combining quantitative research (precourse and postcourse surveys, clinical skill simulation assessments) and qualitative research (analysis of student reflective reports, in-depth interviews with teachers and students).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSetting\u003c/h2\u003e\u003cp\u003eThe study was conducted at Southern Medical University and its affiliated hospitals (The Eighth Affiliated Hospital, Nanfang Hospital, Zhujiang Hospital) from September 2023 to June 2024. The EXE course was carried out in Eighth Affiliated hospitals, covering departments such as emergency departments, narrative sharing centers, health management centers, and medical research centers.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCharacteristics of the participants\u003c/h3\u003e\n\u003cp\u003eThe research subjects were 600 undergraduate students of the 2023 clinical medicine major at Southern Medical University, including 3 classes (300 students) at the First Clinical Medical College (Nanfang Hospital) and 3 classes (300 students) at the Second Clinical Medical College (Zhujiang Hospital). The inclusion criteria were as follows: students who completed all course links (theoretical teaching\u0026thinsp;+\u0026thinsp;practical teaching), participated in precourse and postcourse surveys, and submitted valid reflective reports (word count\u0026thinsp;\u0026ge;\u0026thinsp;500 words, with practical experience and personal insights). The exclusion criteria were as follows: students who did not fully participate in the course, had missing survey data, or whose reflective reports were unqualified (insufficient word count, empty content). Finally, 582 students' reflective reports were included in the analysis, with an effective rate of 97.00%. The sample size was determined on the basis of the principle of \"10\u0026ndash;15 samples per variable\" in quantitative research, and the number of research variables (such as professional enthusiasm, career awareness, and clinical thinking) was approximately 40, so a sample size of 600 was considered sufficient.\u003c/p\u003e\n\u003ch3\u003eCurriculum Design and Implementation\u003c/h3\u003e\n\u003cp\u003eThis course was developed in line with the curriculum framework of ECE for undergraduate clinical medicine programs, running across three consecutive semesters\u0026mdash;from the second half of the first academic year to the second half of the second academic year. It had a total of 32 instructional hours, was split into 8 hours of theoretical teaching and 24 hours of practical teaching, and was assigned 1 academic credit. The assessment adopted a pass/fail binary system, with formative assessment accounting for 80% (including performance in practical participation and skill training) and summative assessment accounting for 20% (based on students\u0026rsquo; reflective reports). The course was organized and implemented by the Science and Education Department of the affiliated hospital, with teaching tasks jointly undertaken by functional departments (such as the Medical Administration Department and Nursing Department) and clinical teaching and research sections (including internal medicine, surgery, and medical imaging), ensuring the integration of theoretical knowledge and clinical practice throughout the teaching process.\u003c/p\u003e\n\u003ch3\u003eTheoretical Teaching (8 Class Hours)\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eSubject Classification and Career Planning (2 Class Hours)\u003c/h2\u003e\u003cp\u003eThis module systematically elaborates on the structure of medical academic training, covering undergraduate, postgraduate, and doctoral stages, as well as the core professional competencies required of clinical physicians\u0026mdash;such as clinical skills, interpersonal communication skills, and humanistic literacy. The teaching was led by senior clinical teachers with more than 10 years of clinical and teaching experience, who adopted a \u0026ldquo;case-driven\u0026thinsp;+\u0026thinsp;interactive guidance\u0026rdquo; method. For example, they introduced the development history of internal medicine subspecialties (e.g., cardiology, gastroenterology) through the career paths of renowned physicians and guided students to fill out a \u0026ldquo;personal career inventory\u0026rdquo; on the basis of their interests (e.g., \u0026ldquo;interest in surgical operations\u0026rdquo; or \u0026ldquo;preference for chronic disease management\u0026rdquo;) and academic strengths (e.g., \u0026ldquo;excellent experimental skills\u0026rdquo; or \u0026ldquo;strong communication ability\u0026rdquo;). During the interaction, most students initially expressed vague career orientations (e.g., \u0026ldquo;want to be a good doctor\u0026rdquo;); after the module, 78% of the students could clearly name 1\u0026ndash;2 target specialties (e.g., \u0026ldquo;considering neurology due to interest in brain science\u0026rdquo;) and raised questions about postgraduate training pathways (e.g., \u0026ldquo;what are the differences between clinical medicine master\u0026rsquo;s and professional master\u0026rsquo;s programs?\u0026rdquo;), reflecting a significant improvement in their career planning awareness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare Systems and Hospital Operations (2 Class Hours)\u003c/h2\u003e\u003cp\u003eThe content of this module focused on introducing China\u0026rsquo;s three-tier healthcare service system and the organizational structure of general hospitals, including administrative departments, clinical departments, and medical technology support departments (such as the Medical Imaging Department and Clinical Laboratory Department). It also details key hospital systems such as medical quality control protocols and patient privacy protection regulations, aiming to deepen students\u0026rsquo; basic understanding of the medical industry\u0026rsquo;s operational framework and clinical service processes. The teaching team included both hospital administrators (e.g., the director of the Medical Administration Department) and clinical department heads. They used \u0026ldquo;onsite mapping\u0026thinsp;+\u0026thinsp;scenario simulation\u0026rdquo; to enhance understanding: for example, they distributed the organizational structure diagram of the affiliated hospital and invited students to simulate the process of a patient with \u0026ldquo;acute myocardial infarction\u0026rdquo; being transferred from the emergency department to the cardiology ward, requiring students to identify the participating departments (emergency, imaging, cardiology, and pharmacy) and their collaborative roles. Students initially struggled to connect the functions of different departments (e.g., forgetting that the Clinical Laboratory Department needs to issue emergency blood test reports); after 3 rounds of simulation, more than 90% of the students could accurately describe the entire collaborative workflow, and some students proactively asked about \u0026ldquo;how to handle cross-departmental communication delays,\u0026rdquo; revealing a shift from \u0026ldquo;memorizing department functions\u0026rdquo; to \u0026ldquo;understanding system operation logic.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eNarrative Medicine (4 Class Hours)\u003c/h3\u003e\n\u003cp\u003eGuided by Yang Xiaolin\u0026rsquo;s Chinese narrative medicine and medical professionalism \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, this module integrates typical clinical cases\u0026mdash;such as narratives of tumor patients\u0026rsquo; diagnosis and treatment processes and cases of medical dispute mediation\u0026mdash;to teach students the integrated application of narrative thinking and evidence-based thinking. The teaching was led by professors specializing in narrative medicine, who adopted a \u0026ldquo;storytelling\u0026thinsp;+\u0026thinsp;role-playing\u0026rdquo; approach. First, they shared the narrative of a breast cancer patient \u0026ldquo;from diagnosis anxiety to treatment adherence\u0026rdquo; (with the patient\u0026rsquo;s consent for anonymization), guiding students to identify the patient\u0026rsquo;s unmet psychological needs (e.g., fear of chemotherapy side effects, worry about family financial burden). Then, the students were divided into groups to simulate \u0026ldquo;doctor‒patient communication scenarios\u0026rdquo;: one student played a \u0026ldquo;patient with early lung cancer\u0026rdquo; (expressing concerns about \u0026ldquo;whether surgery will affect future work\u0026rdquo;), and another played a \u0026ldquo;clinician\u0026rdquo; who needed to use narrative skills to respond. During the simulation, most students initially focused on explaining medical knowledge (e.g., \u0026ldquo;surgery has a 90% cure rate\u0026rdquo;) and ignored emotional resonance; after the teacher\u0026rsquo;s guidance (e.g., \u0026ldquo;first acknowledge the patient\u0026rsquo;s worry: \u0026lsquo;I understand you\u0026rsquo;re concerned about work after surgery\u0026rsquo;\u0026rdquo;), more than 60% of the students could combine \u0026ldquo;empathy expression\u0026thinsp;+\u0026thinsp;information delivery\u0026rdquo; in the second round of role-playing. After class, many students mentioned in their short reflections that \u0026ldquo;I used to think doctors only need to be good at treating diseases; now, I know that listening to patients\u0026rsquo; stories is also a kind of treatment.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003ePractical Teaching (24 Class Hours)\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eHospital visits (20 class hours)\u003c/h2\u003e\u003cp\u003eThe students were divided into small groups of 5\u0026ndash;6, each led by a clinical instructor with at least 5 years of clinical experience. The instructors received unified pretraining, including \u0026ldquo;student guidance norms\u0026rdquo; (e.g., prohibiting taking photos of patients without consent, maintaining a quiet attitude during ward rounds) and \u0026ldquo;key observation points\u0026rdquo; (e.g., guiding students to note the doctor\u0026rsquo;s body language during patient communication). The groups visited key hospital units such as: ①Emergency Department: Instructors first explained the \u0026ldquo;triage principle\u0026rdquo; (prioritizing severe cases) and then guided students to observe the rescue of a \u0026ldquo;patient with acute asthma.\u0026rdquo; During the observation, instructors asked targeted questions: \u0026ldquo;Why does the nurse first give oxygen instead of taking blood tests?\u0026rdquo; Students initially answered \u0026ldquo;because oxygen is more urgent\u0026rdquo;; the instructor further explained \u0026ldquo;this is based on the \u0026lsquo;ABC principle\u0026rsquo; of emergency rescue (Airway, Breathing, Circulation),\u0026rdquo; helping students connect clinical practice with basic medical knowledge. After the observation, 85% of the students could list the 3 core steps of emergency triage.② Narrative Sharing Center: Instructors invited recovered patients to share their disease experiences (e.g., a diabetic patient\u0026rsquo;s \u0026ldquo;struggle with diet control\u0026rdquo;). Before sharing, instructors taught students \u0026ldquo;active listening skills\u0026rdquo; (e.g., maintaining eye contact, nodding to respond); after sharing, students were encouraged to ask follow-up questions (e.g., \u0026ldquo;What advice do you have for doctors communicating with diabetic patients?\u0026rdquo;). Most students initially hesitated to interact, but after the first student asked a question, others followed\u0026mdash;with more than 70% of the students participating in the discussion\u0026mdash;and some students recorded the patient\u0026rsquo;s advice in their notebooks (e.g., \u0026ldquo;Doctors should explain diet plans in simple terms, not just list taboos\u0026rdquo;). ③Medical imaging departments: Instructors demonstrated the operation process of a CT machine and explained \u0026ldquo;how to protect patients\u0026rsquo; radiation safety\u0026rdquo; (e.g., using lead aprons for nonexamin parts). They then guided students to compare the CT images of a \u0026ldquo;normal lung\u0026rdquo; and a \u0026ldquo;pneumonia lung,\u0026rdquo; asking students to identify the differences. Students initially struggled to distinguish the \u0026ldquo;ground-glass opacity\u0026rdquo; in pneumonia images; after the instructor used a \u0026ldquo;cloud covering the sky\u0026rdquo; analogy, more than 90% of the students correctly pointed out the abnormal area. Each department visit lasted 2\u0026ndash;3 hours, and the students were required to complete onsite observation notes. Instructors checked the notes daily and provided feedback (e.g., \u0026ldquo;You recorded the doctor\u0026rsquo;s ward round content in detail; next time you can add your own questions, such as \u0026lsquo;why this treatment plan was chosen\u0026rsquo;\u0026rdquo;).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHoliday Practice (4 Class Hours)\u003c/h2\u003e\u003cp\u003eDuring holidays, students take part in three types of practical activities, with each activity supervised by a dedicated instructor (clinical nurses for ward volunteering, community health workers for science popularization):\u003c/p\u003e\u003cp\u003e① Outpatient guidance: Under the guidance of nurses, students assisted patients with self-service registration and provided department navigation. Instructors taught students \u0026ldquo;elderly friendly communication skills\u0026rdquo; in advance (e.g., speaking slowly, using dialects if necessary). For example, when an elderly patient could not operate the self-service machine due to poor eyesight, a student initially tried to explain the steps verbally but failed; after the instructor reminded \u0026ldquo;you can hold the patient\u0026rsquo;s hand to operate together,\u0026rdquo; the student successfully helped the patient complete registration. The student later wrote in the practice log: \u0026ldquo;I used to think guidance was just telling directions; now I know it\u0026rsquo;s about adapting to the patient\u0026rsquo;s needs.\u0026rdquo;\u003c/p\u003e\u003cp\u003e② Ward Nursing Volunteering: Students accompanied hospitalized patients to chat and help with basic daily care (e.g., helping bedridden patients turn over) under the supervision of nursing staff. Instructors emphasized \u0026ldquo;respecting patient privacy\u0026rdquo; (e.g., knocking before entering the ward, avoiding discussing the patient\u0026rsquo;s condition in public). One student mentioned in the log, \u0026ldquo;A grandma with a fractured leg was in a bad mood; I chatted with her about her grandchildren, and she smiled. The nurse told me that \u0026lsquo;accompanying is also a form of care\u0026rsquo;\u0026mdash;this made me understand the importance of humanistic care.\u0026rdquo;\u003c/p\u003e\u003cp\u003e③ Community health education volunteering: Students delivered popular science lectures on common disease prevention (e.g., \u0026ldquo;how to prevent hypertension\u0026rdquo;) in local communities, with instructors reviewing the lecture content in advance and guiding students to use \u0026ldquo;everyday examples\u0026rdquo; (e.g., comparing blood pressure to \u0026ldquo;water pressure in a water pipe\u0026rdquo;). Initially, students used too many professional terms (e.g., \u0026ldquo;systolic blood pressure\u0026rdquo;); after the instructor\u0026rsquo;s revision, they changed it to \u0026ldquo;the top number in blood pressure, which represents the pressure when the heart beats,\u0026rdquo; making the lecture more accessible. After the activity, community residents gave positive feedback, with some asking for \u0026ldquo;more lectures on children\u0026rsquo;s health.\u0026rdquo;\u003c/p\u003e\u003cp\u003eAfter the holiday, students needed to submit a written report summarizing their practical experiences and insights, along with a parallel medical record\u0026mdash;a key exercise in narrative medicine that combines objective medical data with the patient\u0026rsquo;s subjective experience of illness. The instructors graded the reports on the basis of \u0026ldquo;depth of reflection\u0026rdquo; and \u0026ldquo;application of narrative skills\u0026rdquo; and held a postpractice sharing meeting where outstanding students shared their experiences (e.g., \u0026ldquo;how to use narrative thinking to comfort patients\u0026rdquo;), further promoting peer learning.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eResearch Tools\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eSurvey Questionnaire\u003c/h2\u003e\u003cp\u003eA self-designed structured questionnaire was used, which was divided into precourse and postcourse versions.The pre-course (2024) and post-course (2025) questionnaires were self-developed based on the narrative medicine-based ECE course objectives, relevant validated scales \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, and expert consultation (3 medical education, 2 narrative medicine experts\u0026mdash;who suggested adding \u0026ldquo;no significant change\u0026rdquo; to Likert scales). They went through item generation, expert review (CVI\u0026thinsp;\u0026lt;\u0026thinsp;0.8 items eliminated), pilot tests (50 undergraduates, Cronbach\u0026rsquo;s α: 0.78/0.82), and finalization.\u003c/p\u003e\u003cp\u003ePrecourse survey: This survey included 8 questions distributed 1 week before the course and focused on students' major choice motivations (interest in medicine, family influence, social status and income, etc.), professional enthusiasm (very high, above average, average, below average, very low), perceptions of learning difficulty, career intentions (clinical front line, medical research, medical education, etc.), and willingness to pursue further education\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. A total of 520 valid questionnaires were collected, with an effective recovery rate of 86.67%.\u003c/p\u003e\u003cp\u003ePostcourse survey: This survey included 18 questions distributed 1 week after the course, covering curriculum effectiveness evaluation (changes in professional enthusiasm, impact of each module on career awareness, establishment of clinical thinking), NM application assessment (understanding and application level, help in doctor‒patient relationships), changes in career planning (adjustment of career intentions, changes in willingness to pursue further education), and curriculum improvement suggestions\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. A total of 546 valid questionnaires were collected, with an effective recovery rate of 91.00%.\u003c/p\u003e\u003cp\u003eStudent Learning Materials (Reflective Reports)\u003c/p\u003e\u003cp\u003eAccording to the course requirements, students need to submit a reflective report of no less than 500 words, including practical experiences (details of hospital visits and holiday practice), changes in career perception (before and after the course), insights into humanistic literacy (understanding doctor‒patient communication, empathy, etc.), and the application of NMs (specific cases of applying NMs in practice), and attach at least 2 pictures related to the practice. The research team formulated a unified coding standard and coded the report content in five dimensions: \"career cognition\", \"clinical thinking\", \"humanistic literacy\", \"NM application\", and \"course suggestions\".\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eData collection and analysis\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eThe quantitative data were collected through an online questionnaire platform (Questionnaire Star), and the data were cleaned with Excel 2021 (to eliminate questionnaires with missing key information or obvious logical errors).\u003c/p\u003e\u003cp\u003eQualitative data: Collected through the course management system (students upload reflective reports online), the research team checked the completeness of the reports (word count, pictures, content integrity) before analysis.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eFor quantitative analysis, SPSS 26.0 software was used for descriptive statistical analysis. Count data (such as the proportion of students with improved professional enthusiasm) were expressed as n (%), and measurement data (such as clinical skill simulation assessment scores) were expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s.\u003c/p\u003e\u003cp\u003eQualitative analysis: The thematic analysis method was used. First, two researchers independently read the reflective reports to familiarize themselves with the data; then, they extracted initial codes (such as \"realizing the responsibility of doctors\" and \"learning to communicate with patients in plain language\"); next, they merged similar codes into subthemes (such as \"career cognition improvement\" and \"communication skill enhancement\"); and finally, they summarized the subthemes into core themes (such as \"the course promotes the improvement of students' professional quality\"). When there was a disagreement in coding, a third researcher participated in the discussion to reach a consensus, ensuring that the interrater reliability exceeded 0.8.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eBasic situation of the research subjects\u003c/h2\u003e\u003cp\u003eIn the postcourse survey, the distribution of student classes was as follows: 106 students (19.41%) in Class 1 of Grade 1, 90 students (16.48%) in Class 2 of Grade 1, 107 students (19.60%) in Class 3 of Grade 1, 66 students (12.09%) in Class 1 of Grade 2, 80 students (14.65%) in Class 2 of Grade 2, and 97 students (17.77%) in Class 3 of Grade 2. There were 320 males (58.61%) and 226 females (41.39%), which was roughly consistent with the gender ratio of clinical medicine majors. Among the 582 reflective reports included in the analysis, 538 (92.44%) met the word count requirement and had substantial content, and 44 (7.56%) had insufficient word counts but contained extractable valid information.\u003c/p\u003e\u003cp\u003ePrecourse Baseline Cognition of Students\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eMajor Choice Motivation\u003c/h2\u003e\u003cp\u003e\u003cb\u003eA total of\u003c/b\u003e 249 students (47.88%) chose clinical medicine because of \"strong interest in medicine\", 157 students (30.19%) were influenced by \"family or friends' recommendations\", 81 students (15.58%) considered \"social status and income\", and 33 students (6.35%) had other reasons (such as \"wanting to help others\").\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eProfessional Enthusiasm\u003c/h2\u003e\u003cp\u003e\u003cb\u003eA total of\u003c/b\u003e 303 students (58.27%) had \"above average\" enthusiasm for their major, 130 students (25.00%) had \"average\" enthusiasm, 71 students (13.65%) had \"very high\" enthusiasm, and only 16 students (3.08%) had \"below average\" or \"very low\" enthusiasm.\u003c/p\u003e\u003cp\u003eCareer Orientation and Willingness to Pursue Further Education\u003c/p\u003e\u003cp\u003eBefore the course, 62.11% of the students tended to be \"clinical frontline doctors\", 28.46% considered \"medical research\", and the rest chose other directions (such as medical education and medical administration). With respect to the willingness to pursue further education, 59.23% of the students desired to pursue further education, 22.31% were undecided, and 18.46% had no intention to pursue further education.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eCourse Effectiveness Evaluation Results\u003c/h2\u003e\u003cp\u003eChanges in Professional Enthusiasm and Career Perception\u003c/p\u003e\u003cp\u003eAfter the course, 27.66% of the students had \"significantly improved\" professional enthusiasm, 56.59% had \"somewhat improved\", and only 2.19% (11 students with \"somewhat decreased\" enthusiasm and 1 student with \"significantly decreased\") had decreased enthusiasm.\u003c/p\u003e\u003cp\u003eThe impact of each course module on students' career awareness is shown in Table\u0026nbsp;1. \"Healthcare systems and hospital operations\" and \"hospital visit practices\" had the highest impact proportions (67.77% and 67.03%, respectively), followed by \"subject classification and career planning\" (57.14%), \"NM theory and practice\" accounted for 40.29%, and \"holiday practice activities\" had the lowest impact proportion (15.20%).\u003c/p\u003e\u003cp\u003eIn the reflective reports, 93.13% of the students (542 reports) mentioned positive changes in career perception. For example, one student wrote, \"Witnessing the emergency rescue process in the emergency department and the communication between doctors and the families of brain-dead patients in neurosurgery, I deeply realized that the medical profession is not only about mastering professional technology but also about shouldering the responsibility of saving lives and accompanying patients through difficult times.\" Another student mentioned, \"The visit to the health management center made me understand that medicine is not only about treating diseases but also about preventing diseases. It is also a kind of medical responsibility to help the subhealthy population build a health defense line.\"\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eImpact of Course Modules on Career Cognition (n\u0026thinsp;=\u0026thinsp;546)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCourse Module\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of Choices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProportion (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare systems and hospital operations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e370\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital visit practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubject classification and career planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e312\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNarrative Medicine theory and practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoliday practice activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal (multiple choices allowed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eNote: The sample size was 546. Since some students selected multiple options, the total number of choices was greater than 546.\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eCultivation Effects of Clinical Thinking and Abilities\u003c/h2\u003e\u003cp\u003e\u003cb\u003eA total of\u003c/b\u003e 82.23% of the students believed that the course helped establish preliminary clinical thinking, 27.47% of whom thought it was \"very helpful\", and 54.76% thought it was \"somewhat helpful\".\u003c/p\u003e\u003cp\u003eThe effects of the course on enhancing students' various levels of awareness and ability are shown in Table\u0026nbsp;2. \"Humanistic care awareness\" had the highest enhancement proportion (71.79%), followed by \"doctor‒patient communication skills\" (68.86%), \"clinical thinking ability\" (60.07%), \"professional responsibility\" (54.03%), and \"team collaboration ability\" (53.85%), while only 2.93% of the students thought that there was no significant change.\u003c/p\u003e\u003cp\u003eIn the reflective reports, 65.29% of the students (380 reports) recorded the process of establishing clinical thinking. For example, one student wrote after the internship in the Department of Respiratory and Critical Medicine: \"In the morning case discussion, the attending doctor analyzed the patient's condition from multiple angles such as symptoms, medical history, and examination indicators, and formulated a personalized treatment plan. This made me realize that clinical thinking is not the mechanical application of textbook knowledge but rather the comprehensive analysis and judgment on the basis of the actual situation of patients.\" Another student mentioned, \"When observing laparoscopic surgery, the chief surgeon predicted the possible variation of the bile duct in advance and made corresponding preparations. This let me know that clinical thinking also includes the prediction and response to potential risks.\" In addition, phrases such as \"the importance of aseptic operation\", \"the rigor of medical record writing\", and \"the necessity of multidepartment collaboration\" appeared many times in the reports, which further confirmed the effectiveness of the course in cultivating clinical ability.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEffect of the Course on Enhancing Students' Awareness and Ability (n\u0026thinsp;=\u0026thinsp;546)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAwareness/Ability Dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of Choices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProportion (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHumanistic care awareness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctor‒patient communication skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e376\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical thinking ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional responsibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeam collaboration ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo significant change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1379\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e\u003cem\u003e\u0026nbsp;Same\u003c/em\u003e\u003cem\u003e\u0026nbsp;as Table 1.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecognition of Practical Links and Assessment Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA total of\u0026nbsp;\u003c/strong\u003e86.26% of the students believed that practical links (hospital visits, holiday practices) were \u0026quot;very helpful\u0026quot; (32.05%) or \u0026quot;relatively helpful\u0026quot; (54.21%); 87.54% of the students recognized the assessment method of \u0026quot;formative assessment (80%) + summative assessment (20%)\u0026quot;, of which 33.88% thought it was \u0026quot;very reasonable\u0026quot; and 53.66% thought it was \u0026quot;relatively reasonable\u0026quot;, and only 2.57% (12 students thought it was \u0026quot;not very reasonable\u0026quot; and 2 students thought it was \u0026quot;very unreasonable\u0026quot;) thought it needed adjustment.\u003c/p\u003e\n\u003cp\u003eIn the reflective reports, 88.66% of the students (516 reports) gave positive evaluations of practical links. For example, one student wrote after volunteering as an outpatient guide: \u0026quot;When helping elderly patients operate the self-service registration machine, I had to slow down my speech and repeat the operation steps patiently. This kind of communication experience cannot be learned from textbooks, and it made me understand the importance of adapting to the communication needs of different patients.\u0026quot; Another student mentioned, \u0026quot;Participating in ward rounds in the obstetrics department allowed me to see how doctors, nurses, and midwives cooperate to ensure the safety of mothers and infants. Every detail in the collaboration reflects the responsibility for life.\u0026quot; With respect to the assessment method, one student suggested in the report, \u0026quot;Writing a reflective report helps me sort out the gains and insights from the practice. I hope that in the future, periodic practice logs can be added to facilitate timely summary and improvement.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecial\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eassessment results of the narrative medicine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComprehension and Application Ability\u003c/p\u003e\n\u003cp\u003eA total of 69.23% of the students could master the application of NM, of which 19.60% were \u0026quot;proficient in application\u0026quot; and 49.63% \u0026quot;understood and partially applied\u0026quot;; 25.27% \u0026quot;understood the basic concepts but had difficulty applying\u0026quot;; and only 5.49% (29 students \u0026quot;only understood the concept\u0026quot; and 1 student \u0026quot;still did not understand\u0026quot;). A total of 85.35% of the students believed that NM was \u0026quot;very helpful\u0026quot; (28.94%) or \u0026quot;relatively helpful\u0026quot; (56.41%) for understanding doctor\u0026ndash;patient relationships.\u003c/p\u003e\n\u003cp\u003eIn the reflective reports, 62.37% of the students (363 reports) recorded specific cases of applying NM in practice. For example, one student wrote, \u0026quot;When the teaching doctor explained the condition to a cancer patient, he first handed the patient a glass of warm water to ease the patient\u0026apos;s tension and then used the metaphor of \u0026apos;weeds in the garden\u0026apos; to explain the growth of tumors. This \u0026apos;empathy - explanation - confirmation\u0026apos; communication method is exactly what we learned in the NM class.\u0026quot; Another student mentioned, \u0026quot;In the gastroenterology department, I tried to explain the meaning of \u0026apos;elevated creatinine\u0026apos; to the patient in plain language, from the function of the kidneys to the possible reasons for the increase. The patient\u0026apos;s expression changed from anxiety to understanding, which made me realize that NMs can build a trust bridge between doctors and patients.\u0026quot; In addition, one student reflected: \u0026quot;Facing critically ill patients, I once did not know how to comfort them. Through learning NM, I understand that listening carefully to patients\u0026apos; concerns and accompanying them silently is also a kind of treatment.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapplication intentions and improvement needs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA total of\u0026nbsp;\u003c/strong\u003e87.91% of the students would \u0026quot;certainly\u0026quot; (31.87%) or \u0026quot;probably\u0026quot; (56.04%) apply NM in future studies and work; 43.22% of the students thought that NM education should strengthen \u0026quot;practical application\u0026quot;, 31.50% suggested increasing \u0026quot;case analysis\u0026quot;, and 20.70% hoped to deepen \u0026quot;theoretical depth\u0026quot;.\u003c/p\u003e\n\u003cp\u003eIn the reflective reports, 58.08% of the students (338 reports) proposed suggestions for NM teaching. For example, one student suggested, \u0026quot;I hope to increase NM workshops, set up simulated doctor‒patient communication scenarios, and let us practice the application of NM in real situations.\u0026quot; Another student mentioned, \u0026quot;Writing parallel medical records can help me record patients\u0026apos; disease stories and personal feelings. It is suggested to increase such practical tasks in the course to improve the ability to apply NM.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChanges in Career Planning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCareer Intention\u003c/p\u003e\n\u003cp\u003eAfter the course, 88.28% of the students tended to engage in \u0026quot;clinical frontline work\u0026quot; after graduation, 40.66% considered \u0026quot;medical research\u0026quot; (some students chose both clinical work and research), 30.77% focused on \u0026quot;medical education\u0026quot;, and only 6.41% indicated \u0026quot;not engaging in medical-related work\u0026quot;.\u003c/p\u003e\n\u003cp\u003eWillingness to Pursue Further Education\u003c/p\u003e\n\u003cp\u003eA total of 75.09% of the students had an increased willingness to pursue further education, 31.32% \u0026quot;significantly increased\u0026quot; and 43.77% \u0026quot;somewhat increased\u0026quot;; 22.53% had \u0026quot;no change\u0026quot;; and only 2.38% (11 students \u0026quot;somewhat decreased\u0026quot; and 2 students \u0026quot;significantly decreased\u0026quot;) had a decreased willingness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdjustment of Career Planning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA total of\u0026nbsp;\u003c/strong\u003e58.79% of the students had \u0026quot;tentative changes\u0026quot; in their career planning (such as clarifying the direction of specialized disciplines), 36.63% \u0026quot;maintained the original plan\u0026quot;, and only 4.21% \u0026quot;became more uncertain\u0026quot;.\u003c/p\u003e\n\u003cp\u003eIn the reflective reports, 72.16% of the students (419 reports) mentioned adjustments in career planning. For example, one student wrote after the internship in the Department of Cardiovascular Medicine: \u0026quot;Seeing doctors race against time to rescue patients with myocardial infarction, I made up my mind to engage in cardiovascular clinical work in the future. I also realized that I need to improve my professional level through postgraduate study to better cope with complex clinical situations.\u0026quot; Another student mentioned, \u0026quot;The health education activities in the obstetrics maternity school made me interested in medical education. I hope to engage in clinical work while carrying out medical popularization and education work to spread medical knowledge to more people.\u0026quot;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eThe integration of narrative medicine into ECE is in line with the needs of medical education reform\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study revealed that after the course, 84.25% of the students had improved professional enthusiasm, and 82.23% had established preliminary clinical thinking. In the reflective reports, over 93% of the students mentioned the positive impact of the course on career awareness and humanistic literacy. This result is consistent with the \"early clinical\" education philosophy advocated by the \"China Undergraduate Medical Education Standards\". Traditional ECE courses usually focus on \"process cognition and clinical skill training\" \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, whereas this course, through the \"medical system theory\u0026thinsp;+\u0026thinsp;hospital visit practice\" model, allows students to intuitively experience the \"urgency of emergency rescue\" and the \"transmission of patient stories in the narrative sharing center\" \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. This \"theory-scenario-experience\" closed-loop design effectively connects basic medicine and clinical practice, enhances students' professional immersion and identity, which is consistent with Simmenroth et al.'s conclusion that \"ECE can enhance medical students' professional identity\" \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e Notably, the integration of the NM module significantly improved students' humanistic literacy: 71.79% of the students had increased humanistic care awareness, and 62.37% of the students recorded NM application cases in their reflective reports. This result confirms Yang Xiaolin et al.'s view that NMs can effectively cultivate medical students' empathy through \"patient perspective simulation\" and \"disease narrative analysis\" \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e and compensate for the deficiency of traditional medical education, which focuses on technology and ignores humanity. For example, students frequently mentioned \"explaining medical conditions in plain language\" and \"listening to patients' psychological needs\" in their reports, which reflects that NM has effectively cultivated students' \"holistic medical concept\".\u003c/p\u003e\n\u003ch3\u003eThe Differentiated Effects of Course Modules Provide Directions for Teaching Optimization\u003c/h3\u003e\n\u003cp\u003eThe data on the impact of career cognition show that the impact proportions of \"healthcare systems and hospital operations\" (67.77%) and \"hospital visit practice\" (67.03%) are significantly greater than those of \"NM\" (40.29%), and 93.13% of the career cognition descriptions in students' reflective reports also focus on these two modules. This is related to the cognitive characteristics of lower-grade students: freshmen majoring in clinical medicine are in the \"industry cognition enlightenment stage\", and they need to establish a professional framework through macrosystem explanations and concrete scenario experiences. The in-depth application of NM requires more clinical practice accumulation \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, so its impact on students' initial career cognition is relatively limited.\u003c/p\u003e\u003cp\u003eIn addition, the participation rate of \"holiday practice activities\" was relatively low (15.20%), and only 15% of the students mentioned holiday practices in their reports. This may be due to the conflict between practice time and students' holiday arrangements (such as make-up classes and family trips). In the future, the practice time and form should be optimized, such as by adopting an \"online\u0026thinsp;+\u0026thinsp;offline\" combined volunteer service model (online: popularizing medical knowledge through short videos; offline: participating in community health services on weekends), to improve students' participation.\u003c/p\u003e\u003cp\u003eIn the special assessment of the NM, 43.22% of the students suggested strengthening \"practical application\", and 58.08% of the students proposed similar needs in their reports (such as increasing simulated communication and parallel medical record writing). This reflects that the current NM teaching still focuses on \"theoretical explanation\u0026thinsp;+\u0026thinsp;case analysis\" and lacks practical operation links. Savitha et al. noted that practical NM teaching (such as allowing students to write patient disease narratives) can significantly improve students' application ability \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Therefore, in the future, modules such as \"clinical narrative workshops\" and \"standardized patient-simulated communication\" can be added to the course, and clinical teachers can guide students to apply NM to actual doctor‒patient communication to promote the transformation of narrative thinking into clinical practice ability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Course highlights the guiding role of career planning and reflects the long-term value of medical education\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter the course, 88.28% of the students tended to engage in clinical frontline work, and 75.09% of the students had an increased willingness to pursue further education. In the reflective reports, 72.16% of the students mentioned adjustments in career planning. This shows that the course, through the progressive design of \"department visit - career awareness - skill training\", helps students clarify their career directions. For example, high-intensity clinical scenarios in the emergency department help students realize the importance of \"solid professional knowledge and rapid decision-making ability\", thus increasing their willingness to pursue further education to improve their professional level. NM cases also attract some students' attention to \"medical education\" and \"medical research\" (such as participating in patient narrative collection and sorting and being interested in medical humanities research), which reflects the course's guiding role in promoting the diversified development of students' careers.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eResearch advantages and limitations\u003c/h2\u003e\u003cdiv id=\"Sec32\" class=\"Section3\"\u003e\u003ch2\u003eAdvantages\u003c/h2\u003e\u003cdiv id=\"Sec33\" class=\"Section4\"\u003e\u003ch2\u003eLarge Sample Size and High-Quality Data Ensure Result Reliability\u003c/h2\u003e\u003cp\u003eThis study enrolled 600 undergraduates from two clinical medical colleges of Southern Medical University, covering students of different grades and genders. The sample size meets the principle of \"10\u0026ndash;15 samples per variable\" for quantitative research (involving approximately 40 variables such as professional enthusiasm and clinical thinking). Eventually, 582 reflective reports were included in the analysis (with an effective rate of 97.00%), and 92.44% of these reports met the requirements of \"\u0026ge;500 words, including practical experiences and personal insights\". This large sample size effectively reduces random errors, while high-quality primary data records the authentic experiences and cognitive changes of students, providing sufficient empirical support for the conclusions and significantly enhancing the representativeness and reliability of the results.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eMixed Research Methods Avoid Limitations of Single Methods\u003c/h2\u003e\u003cp\u003eThe study innovatively adopted a \"quantitative\u0026thinsp;+\u0026thinsp;qualitative\" mixed research method, which effectively compensates for the inherent defects of single research methods. This design aligns with the application advocacy of mixed methods in medical education research, where purely quantitative assessment is prone to \"reductionism tendencies\", while purely qualitative research has limitations in generalizability. In the quantitative dimension, pre-course and post-course comparative questionnaires (with effective recovery rates of 86.67%\u0026ndash;91.00%) and clinical skill simulation assessments were used to systematically quantify changes in indicators such as students' professional enthusiasm and clinical thinking, with the empathy ability score reaching 85.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98, providing objective quantitative evidence for course effectiveness. In the qualitative dimension, thematic analysis was applied to code the reflective reports (with inter-rater reliability\u0026thinsp;\u0026gt;\u0026thinsp;0.8), revealing in-depth cognitive changes such as the shift from \"disease-centered cognition to person-centered care concept\". This combination of \"quantitative data verifying effect magnitude\u0026thinsp;+\u0026thinsp;qualitative data revealing internal mechanisms\" forms a complete evidence chain, perfectly aligning with the core value of mixed methods in \"balancing quantitative focus and retaining assessment authenticity\", and avoiding the one-sidedness of single research methods.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eInnovative Course Design Fills Gaps in Medical Humanities Education\u003c/h3\u003e\n\u003cp\u003eThis study is the first to systematically integrate narrative medicine into ECE course for undergraduate clinical medicine students, constructing a \"theory-practice-reflection\" trinity system. This design is not only in line with the requirements of \"ECE and multiple clinical practices\" in the National Standards for Undergraduate Medical Education Quality - Clinical Medicine Program (2022 Edition), but also directly responds to the value of integrating patient perspectives into early medical education. As confirmed by Dijk 's systematic review\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, integrating patient perspectives into early medical education can significantly improve students' patient-centered awareness and communication skills. This study further transforms this concept into operable course practices through modules such as \"narrative sharing center visits and parallel medical record writing\". The data showed that 69.23% of students could apply narrative medicine, and 62.37% recorded application cases, effectively addressing the pain point of \"disconnection between humanities education and clinical practice\" in traditional medical education, and providing a replicable new path for the in-depth integration of medical humanities education and clinical practice.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eSample Representativeness and Selection Bias\u003c/h2\u003e\u003cp\u003e First,the participants were all from one center (Southern Medical University), which is a high-level university with good cooperation between the university and the affiliated hospitals (such as the narrative sharing centers, well-trained instructors, etc.). This may not be the case in other medical colleges or vocational schools in the region, so the research results can hardly be generalized to the overall population of Chinese medical students. Secondly, there was no control group (such as students in the traditional ECE without NM), so we could not make causal inferences about the specific effect of NM. Thirdly, the inclusion criteria (such as completing all modules and submitting valid reflective reports) led to selection bias towards active students, and the positive effects may be overestimated due to the exclusion of some less active participants.\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003eSubjectivity in Data and Lack of Objective Validation\u003c/h2\u003e\u003cp\u003eThe current study was primarily dependent on self-reported data, such as surveys and reflective reports, which are susceptible to social desirability bias. For instance, participants might overstate their perceived improvements to align with anticipated expectations. Although thematic analysis of reflective reports provides valuable insights, it is inherently subject to researchers' subjective interpretations, despite measures like interrater reliability. The absence of objective complementary data, such as standardized patient (SP) evaluations of communication skills or blinded clinician grading of case analyses, to corroborate self-reported outcomes, diminishes the validity of assertions regarding clinical thinking or NM application.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec39\" class=\"Section2\"\u003e\u003ch2\u003eLimited Generalizability to Diverse Contexts\u003c/h2\u003e\u003cp\u003eThe findings of this study are limited to the context of Southern Medical University and the China\u0026rsquo;s Undergraduate Medical Education Standards (2022), which have significant differences from the accreditation frameworks used in other countries (such as the U.S. LCME, European directives). The specific model of NM implemented at this medical school (32-h, semester-based) is also different from the longitudinal patient-following model adopted by most Western medical schools, which has implications for cross-cultural transferability. Furthermore, by focusing on clinical medicine undergraduates, we did not include other health professions undergraduates (e.g., nursing, pharmacy), which further narrowed the generalisability of our findings.\u003c/p\u003e\u003cdiv id=\"Sec40\" class=\"Section3\"\u003e\u003ch2\u003eDirections for Future Research\u003c/h2\u003e\u003cp\u003eTo address these limitations, future studies should adopt the following strategies:conduct multicenter studies across diverse Chinese medical schools (top-tier, regional, vocational) with a traditional ECE control group and randomized controlled trials (RCTs), while expanding eligibility to international samples and other health professions to improve representativeness and cross-context generalizability; establish 1-year and 3-year postcourse longitudinal tracking to measure sustained outcomes (including objective metrics like OSCE scores, teacher evaluations, and patient satisfaction, as well as long-term subjective data such as career choices and NM skill retention) and link data to administrative records (transcripts, residency matches) to assess professional impact,consistent with Ismail et al.\u0026rsquo;s \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e emphasis on balancing formative and summative assessment in medical education.; reduce subjectivity by supplementing self-reports with objective tools (e.g., standardized patient evaluations using validated scales like the Communication Assessment Tool, blinded clinician grading of clinical tasks) and using software (NVivo) for quantitative content analysis of reflective reports to minimize researcher bias; and develop adapted ECE-NM models for resource-limited settings (e.g., VR clinical simulations, online NM modules)\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e],\u003c/sup\u003e test cross-cultural applicability via international collaborations, and incorporate stakeholder perspectives (instructors, patients, educators) to evaluate feasibility and scalability.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEarly clinical exposure (ECE) courses integrated with narrative medicine (NM) adopt a three-dimensional design of \"theory - practice - humanity\", which can effectively enhance the professional identity, clinical thinking, and humanistic literacy of clinical medicine undergraduates and clarify their career planning direction. The students' reflective reports and other learning materials further confirmed the practical value of the course: more than 90% of the students recorded positive changes in their career awareness and humanistic literacy during the course, and more than 60% reflected on the application of clinical thinking and NM. This course conforms to the development needs of modern medical education, which is \"early clinical, more humanistic\". In the future, it is necessary to further optimize the NM practical module (increase simulated communication and practical tasks) and adjust the holiday practice arrangement (adopt online and offline combinations) to provide a more replicable and promotable teaching model for the reform of ECE in medical education.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNarrative Medicine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eECE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eearly clinical exposure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of The Eighth Affiliated Hospital, Southern Medical University, and was conducted in accordance with the Declaration of Helsinki. All the participating students were informed of the research purpose, content, and risks and signed written informed consent forms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the protection of students' personal privacy but are available from the corresponding author (Zheng Dayong) upon reasonable request. The student reflective reports used in the study are stored in the course management system of Southern Medical University and can be provided to relevant researchers after the approval of the school's teaching management department and the consent of the corresponding author are obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. None of the authors have financial or nonfinancial relationships with any organizations that may be related to the subject matter of this study (such as pharmaceutical companies or medical education training institutions).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Teaching Reform Project of Southern Medical University (No. JG2023028) and the Digital Experimental Teaching Demonstration Center for Clinical Comprehensive Competence Training of Medical Talents of Guangdong Province Education Department (No. 2024-30-8). The funder participated in the discussion of the course design plan but did not participate in the data collection, analysis, interpretation of results, writing of the paper, or the decision to submit the paper for publication. There is no other external funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors'\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLi Zhao (LZ): Responsible for the design of the research plan, collection of survey data, and sorting of reflective reports.\u003c/p\u003e\n\u003cp\u003eCai Huijuan (CHJ): Participated in the implementation of the course, conducted in-depth interviews with students, and assisted in data analysis.\u003c/p\u003e\n\u003cp\u003eYang Xiaolin (YXL): Guided the design of the NM module, provided theoretical support for NM teaching, and revised the paper.\u003c/p\u003e\n\u003cp\u003eLin jingsong (LJS): Responsible for the organization of practical teaching (such as arranging hospital visits) and collected students' practice records.\u003c/p\u003e\n\u003cp\u003eCao Wenhua (CWH): Participated in the implementation of NM teaching.\u003c/p\u003e\n\u003cp\u003eZhang Peng (ZP): Participated in the clinical skill simulation assessment, scored students' performance, and provided professional clinical advice.\u003c/p\u003e\n\u003cp\u003eRen Jing (RJ): assisted in the coding and analysis of qualitative data (reflective reports) and identified typical cases.\u003c/p\u003e\n\u003cp\u003eZheng Dayong (ZDY): proposed the research topic, designed the overall framework of the study, guided the data analysis, wrote the first draft of the paper, and revised the final version. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participating students for their active cooperation in completing the surveys and writing reflective reports; thank the clinical teachers of the affiliated hospitals of Southern Medical University (including The Eighth Affiliated Hospital, Nanfang Hospital, and Second Clinical Medical College, Southern Medical University, especially Pro.Zheng Weiyang and Pro. Li Xiaodan ) for their support in the practical teaching of the course (such as guiding students' hospital visits and conducting clinical skill training); and thank the staff of the online questionnaire platform (Questionnaire Star) for their technical support in data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLi Zhao: Ph.D.,M.D.,Attending Physician, Associate Research Fellow, majoring in medical education, narrative medicine and clinical practice teaching, with research interests in the reform of ECE for medical students.\u003c/p\u003e\n\u003cp\u003eYang Xiaolin: Professor, Doctoral Supervisor, majoring in narrative medicine and medical humanities education, with research interests in the integration of narrative medicine into clinical medical education.\u003c/p\u003e\n\u003cp\u003eZheng Dayong: Ph.D.,M.D., Chief Physician, majoring in clinical medicine education and teaching management, with research interests in the cultivation of the professional qualities of medical students.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Federation for Medical Education (WFME). WFME Global Standards for Quality Improvement of Basic Medical Education. Copenhagen: WFME; 2021. pp. 12\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAccreditation Council for Graduate Medical Education (ACGME). ACGME Core Competencies.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.acgme.org/What-We-Do/Accreditation/Competencies\u003c/span\u003e\u003cspan address=\"https://www.acgme.org/What-We-Do/Accreditation/Competencies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Mar 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimmenroth A, Harding A, Vallersnes OM, et al. Early clinical exposure in undergraduate medical education: A questionnaire survey of 30 European countries. Med Teach. 2023;45(4):426\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOshiro T, Suzuki S, Kagawa N, et al. Integration of early clinical exposure into curriculum enhances self-assessment of professional competencies in medical practice. BMC Med Educ. 2025;25(1):1139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-025-07678-7\u003c/span\u003e\u003cspan address=\"10.1186/s12909-025-07678-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Person-Centered Care: A Guide for Health Care Providers. Geneva: WHO; 2020. pp. 28\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCharon R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press; 2006. pp. 32\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSavitha D, Iyengar A, Devarbhavi H, et al. Early clinical exposure through a vertical integration programme in physiology. Natl Med J India. 2018;31(5):296\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu CI, Tang KP, Wang YC, Chiu CH. Impacts of early clinical exposure on undergraduate student professionalism\u0026mdash;a qualitative study. BMC Med Educ. 2022;22(1):435. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-022-03505-5\u003c/span\u003e\u003cspan address=\"10.1186/s12909-022-03505-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Education, Working Committee for the Accreditation of Clinical Medicine Programs. China Undergraduate Medical Education Standards - Clinical Medicine Program. (2022 Edition). Beijing: Peking University Medical Press; 2022. pp. 18\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXiaolin Y. Wang Huafeng. The ability of medical narrative and career development. Guangzhou: Guangdong Science and Technology; 2023. pp. 89\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Y, Liu M, et al. Development and validation of the Medical Student Professional Identity Scale. Chin J Med Educ. 2022;42(5):412\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Z, Cai HJ, Yang XL, Cao WH, Lin JS. Early Clinical Practice Pre-Course Questionnaire [Unpublished raw data]. Southern Medical University. Appendix A.​; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Z, Cai HJ, Yang XL, Cao WH, Lin JS. Early Clinical Practice Post-Course Questionnaire [Unpublished raw data]. Southern Medical University. Appendix B; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOshiro T, Suzuki S, Kagawa N, Ono H, Goto R, Furuta A, et al. Integration of early clinical exposure into curriculum enhances self-assessment of professional competencies in medical practice. BMC Med Educ. 2025;25(1):1139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-025-07678-7\u003c/span\u003e\u003cspan address=\"10.1186/s12909-025-07678-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang Xiaolin L, Xinjiang LZ. Narrative Hospital Management: From Lean Management to Value Cocreation. Guangzhou: Guangdong Science and Technology; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimmenroth A, Harding A, Vallersnes OM, et al. Early clinical exposure in undergraduate medical education: A questionnaire survey of 30 European countries. Med Teach. 2023;45(4):426\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSavitha D, Iyengar A, Devarbhavi H, et al. Early clinical exposure through a vertical integration programme in physiology. Natl Med J India. 2018;31(5):296\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDijk SW, Duijzer EJ, Wienold M. Role of Active Patient Involvement in Undergraduate Medical Education: A Systematic Review[J]. BMJ Open. 2020;10(11):e037217. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2020-037217\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2020-037217\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsmail OM, Elbarbary NM, Elsayed NM, et al. Theories and Practices in Learning and Assessment for Postgraduate Medical Education: A Review[J]. Cureus. 2024;16(3):e40127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.40127\u003c/span\u003e\u003cspan address=\"10.7759/cureus.40127\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee YJ, Kim JH, Park JY. Effects of early clinical exposure using virtual reality on learning: A text-mining analysis study[J]. J Educ Eval Health Prof. 2025;22:19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3352/jeehp.2025.22.19\u003c/span\u003e\u003cspan address=\"10.3352/jeehp.2025.22.19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Early Clinical exposure, Narrative Medicine (NM), Clinical Medical Education, Medical Professionalism, Undergraduate Medical Students","lastPublishedDoi":"10.21203/rs.3.rs-7729445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7729445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eGlobal medical education frameworks (WFME, ACGME) stress integrating early clinical exposure (ECE) and humanistic cultivation, but traditional ECE (including some Chinese models) prioritizes procedural familiarity over empathy/doctor‒patient communication, failing the \"bopsychosocial\" model. Narrative medicine (NM) fosters empathy but is rarely integrated into undergraduate ECE. In alignment with China\u0026rsquo;s 2022 China Undergraduate Medical Education Standards, this study tests an NM-integrated \"Early Clinical Practice\" course for clinical undergraduates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe mixed-methods study included 600 2023 Southern Medical University clinical undergraduates. A 32-hour course (8 h theory: career planning, healthcare systems, NM; 24 h practice: hospital visits, holiday practice) was implemented. The data were obtained from prescourse (520 valid) and postcourse (546 valid) surveys, clinical skill assessments, and 582 reflective reports and were analyzed via SPSS 26.0 and thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePostcourse, 84.25% had higher professional enthusiasm, 82.23% had gained preliminary clinical thinking, 71.79% had enhanced humanistic awareness, and 69.23% had applied NM. Clinical skill scores were high (empathy: 85.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98). Over 90% of the reflective reports noted career/humanistic gains.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe NM-integrated course effectively boosts undergraduates\u0026rsquo; professional identity, clinical thinking, and humanistic literacy. Future optimization of NM practices and holiday arrangements is needed.\u003c/p\u003e","manuscriptTitle":"The Effectiveness of the \"Early Clinical Exposure\" Course Based on Narrative Medicine in Cultivating the Professional Qualities of Undergraduates in Clinical Medicine: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 11:50:12","doi":"10.21203/rs.3.rs-7729445/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-03T07:11:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T17:34:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T22:37:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7219120904060027285020224528221681694","date":"2026-01-25T15:28:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250127313909630746962163759361958991057","date":"2026-01-23T15:40:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T12:17:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33668640788999584433506360640963315410","date":"2026-01-07T08:20:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T13:56:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-24T06:55:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-14T14:12:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-14T14:01:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-14T13:57:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"68bc0e01-1217-4ca2-8afa-dcfb30470cd2","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:14:23+00:00","versionOfRecord":{"articleIdentity":"rs-7729445","link":"https://doi.org/10.1186/s12909-026-08885-6","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-03-05 15:59:43","publishedOnDateReadable":"March 5th, 2026"},"versionCreatedAt":"2025-12-01 11:50:12","video":"","vorDoi":"10.1186/s12909-026-08885-6","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08885-6","workflowStages":[]},"version":"v1","identity":"rs-7729445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7729445","identity":"rs-7729445","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}