Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational Study

Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational 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 Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational Study Hye-Yoon Lee, Sunju Im, Sang-Won Shin, Jung-Ae Kim, Jin-Mi Song This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4941094/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Health professions are required to understand social structures and systems, as well as basic and clinical medical knowledge. Accordingly, Health Systems Science (HSS) is recognized as a third party of medical education. The curriculum for HSS is currently being developed and implemented in Korea. This study aimed to evaluate the effectiveness of HSS in Korean medical education. Methods The HSS course using early clinical exposure (ECE) was implemented in Korean medical education and comprised lectures, four ECEs, and group activities. Students and clinical directors evaluated the course using questionnaires focused on systems thinking, productivity of group activities, and satisfaction. Results The study showed significant improvements in systems thinking, especially in team learning (p = .028) and overall systems thinking (p = .017). Key habits related to systems thinking also improved significantly over 15 weeks. ECE reports highlighted student engagement with various HSS domains, focusing on patient care, healthcare structure, and policy. Per the clinical directors’ evaluations, “healthcare structure and process” was the most effective domain among the core domains of HSS. Per the students’ evaluations, the overall satisfaction was higher than the college’s average score, and especially “course structure” and “instructional expertise” domains were rated most effective. Conclusion The HSS course with ECE is an effective method for fostering students' systems thinking habits and enhancing their understanding of healthcare systems and patient-centered care. Verifying whether students' interest in various domains and their systems thinking abilities are sustained over time is necessary, and further research is required to design a longitudinal course with continuity. Health systems science early clinical exposure Korean medicine medical humanities and social medicine Figures Figure 1 Figure 2 Background The medical education curriculum comprises basic and clinical medicine as well as medical humanities and social medicine disciplines [ 1 ]. Medical humanities and social medicine gained prominence later than basic and clinical medicine, as the limitations of the Flexner’s model became apparent, highlighting the need for a holistic approach to medical education [ 2 , 3 ]. Medical humanities and social medicine comprise several disciplines, such as history, philosophy, ethics, law, religion, and social policy. Health Systems Science (HSS) focuses on the healthcare system within the medical humanities and social medicine domains [ 4 , 5 ]. HSS provides a comprehensive understanding of the interrelated factors that influence patient health, with the ultimate goal of providing patient-centered medicine. It is more practical and realistic compared to traditional medical humanities and social medicine domains [ 6 ]. HSS addresses the impact of various factors, including healthcare policy, economics, and structure, on patient health status and healthcare experiences. The dualized healthcare system in Korea, which integrates conventional and Korean medicine (KM), is unique because it offers patients more options. However, it has been criticized for escalating medical costs and causing conflicts among medical professionals[ 7 , 8 ]. This healthcare system requires professionals’ attention to social aspects beyond clinical practice. HSS is considered more suitable for the four-year medical school program because its scope is narrower and more focused. In contrast, the ‘humanities and social medicine’ concept is deemed more appropriate for the six-year medical college curriculum because it encompasses broader areas, including liberal arts[ 9 ]. South Korea has four- and six-year educational programs. The six-year program, which comprised two-year pre-medical and four-year medical courses, has been reformed into a single six-year program. In addition, the South Korean university curricula are categorized into major-required courses and general education courses, with students demonstrating significantly different attitudes towards mandatory courses than general education courses. Considering these factors, it is essential to evaluate which is more suitable between HSS and the humanities and social medicine framework, or whether combining both should be considered. In addition, students tend to show low interest in humanities and social medicine and regard these subjects as unrelated to their primary studies[ 10 ]. Therefore, it is essential to identify appropriate teaching methods for HSS. Early clinical exposure (ECE) refers to exposure to clinical settings in hospitals and the community before the clinical phase, to help students learn about clinical science[ 11 ]. In addition, frequent exposure to medical practice increases the understanding of the medical field and empathy for patients' suffering[ 12 ]. In this study, we aimed to introduce HSS into Korean medical education and evaluate its satisfaction and effectiveness. Methods Study design This prospective observational study collected students’ responses to questionnaires on the study’s purpose and analyzed the outcomes of the course, including the reaction and learning. The Pusan National University Institutional Review Board approved this study (No.2023-150-HR). Subjects All third-year undergraduate students (n = 21) in the integrated bachelor’s master’s (3 + 4) program undertook the course in the second semester of 2023. The students studied basic biomedical sciences and basic liberal arts before taking any clinical course. Consent and recruitment for the questionnaires The questionnaires were administered to only participants who submitted written informed consent. Information regarding study participation was posted on a website and social media. Interested students were provided with written explanations. They were given opportunities to ask questions, after which the students who voluntarily agreed to participate signed a written consent form. The surveys were anonymous and collected no personal information. Participants tracked changes using self-chosen nicknames. Teaching methods (activities during this course) Lectures The lectures explained the concept of HSS core functional, foundational, and linking domains, highlighting that HSS is the third pillar of medical education in basic and clinical sciences. The lectures were delivered by three professors: (1) a medical doctor and a medical education expert, (2) a Korean medical doctor (KMD) and expert in classics in Korean medicine, and (3) a KMD (specialist in Korean internal medicine) and expert in medical education. Case-based discussion The professors developed cases illustrating the complex interrelationships between various domains within HSS. During class, the students analyzed the underlying HSS domains of each case and systematically approached solutions using the think-pair-share method. Below are the case examples used in the discussion: Let us consider the causes and solutions for a 46-year-old male patient with obesity. Let us consider the causes and prevention methods of incidents where acupuncture needles are unintentionally left in a patient’s body after treatment at a KM clinic. Early clinical exposure We formed 10 groups comprising nine duos and one trio and assigned each group to a KM clinic based on their preferences. Over four consecutive weeks, the students visited their designated clinic once weekly for 3 h over. During their visits, the students interviewed the patients, focusing on the interconnections between HSS domains. Basic group activity – ‘early clinical exposure report’ After completing 4-weeks of ECE training, the students systematically analyzed their observations according to HSS domains. Then, each group presented their findings, followed by a Q&A session. Advanced group activity – ‘in-depth investigation report’ During the ECE, each group was free to choose, research, and present a topic of interest. Course evaluation methods The Scale of Systems Thinking The scale of Systems Thinking is a previously developed questionnaire[ 13 ] embedded in the Pusan National University Learning Management System (LMS). The questionnaire was anonymous, and the students used nicknames to track changes over time (Weeks 1, 6, and 15). The scale comprised 20 items on a 5-point Likert scale categorized into five sub-factors: mental model, individual skill, team activity, systems thinking, and shared vision. Self-assessment of the habits of a systems thinker We explained the 14 Habits of a Systems Thinker (Skochelak, Hammoud et al. 2021) presented by the Waters Center for Systems Thinking to the participants. We asked them to rate their competence on a 5-point Likert scale for each item. This questionnaire was embedded in the Pusan National University LMS, and a similar method was used to maintain anonymity and track changes[ 14 ]. The 14 habits are as follows: “H1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system’s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation”[ 14 ]. Early clinical exposure report We analyzed reports systematically summarizing observations made during ECE at each KM clinic according to HSS core domains. The researchers extracted meaningful insights from 10 reports and categorized them according to HSS domains using thematic analysis[ 15 , 16 ]. In-depth investigation report Reports containing detailed investigations on topics of group interest were analyzed and presented. Meaningful insights were extracted and categorized according to HSS domains using thematic analysis. Course evaluation survey of the clinical supervisors After completing the students' field study, a survey was administered to the supervising KMD to assess the program’s effectiveness. The survey inquired about the program’s perceived effectiveness in the seven core domains, four foundational competencies domains, and one linking HSS domain. Responses were collected using a 5-point Likert scale. Course evaluation by students End-of-term course evaluation scores were analyzed. The evaluation results for this course were compared with average college scores. 7) Statistical analysis The survey results were statistically analyzed using descriptive and inferential statistics to evaluate the effects before and after the educational intervention. Descriptive statistics are presented as means and standard deviations. Due to the small sample size, pre- and post-comparisons were performed using non-parametric tests, specifically the Wilcoxon signed-rank test. All statistical analyses were performed using the IBM statistical package for social sciences version 29. Results Methods 1. Study design This prospective observational study collected students’ responses to questionnaires on the study’s purpose and analyzed the outcomes of the course, including the reaction and learning. The Pusan National University Institutional Review Board approved this study (No.2023-150-HR). 2. Subjects All third-year undergraduate students (n=21) in the integrated bachelor’s master’s (3+4) program undertook the course in the second semester of 2023. The students studied basic biomedical sciences and basic liberal arts before taking any clinical course. 3. Consent and recruitment for the questionnaires The questionnaires were administered to only participants who submitted written informed consent. Information regarding study participation was posted on a website and social media. Interested students were provided with written explanations. They were given opportunities to ask questions, after which the students who voluntarily agreed to participate signed a written consent form. The surveys were anonymous and collected no personal information. Participants tracked changes using self-chosen nicknames. 4. Teaching methods (activities during this course) 1) Lectures The lectures explained the concept of HSS core functional, foundational, and linking domains, highlighting that HSS is the third pillar of medical education in basic and clinical sciences. The lectures were delivered by three professors: (1) a medical doctor and a medical education expert, (2) a Korean medical doctor (KMD) and expert in classics in Korean medicine, and (3) a KMD (specialist in Korean internal medicine) and expert in medical education. 2) Case-based discussion The professors developed cases illustrating the complex interrelationships between various domains within HSS. During class, the students analyzed the underlying HSS domains of each case and systematically approached solutions using the think-pair-share method. Below are the case examples used in the discussion: “Let us consider the causes and solutions for a 46-year-old male patient with obesity.” “Let us consider the causes and prevention methods of incidents where acupuncture needles are unintentionally left in a patient’s body after treatment at a KM clinic.” 3) Early clinical exposure We formed 10 groups comprising nine duos and one trio and assigned each group to a KM clinic based on their preferences. Over four consecutive weeks, the students visited their designated clinic once weekly for 3 h over. During their visits, the students interviewed the patients, focusing on the interconnections between HSS domains. 4) Basic group activity – ‘early clinical exposure report’ After completing 4-weeks of ECE training, the students systematically analyzed their observations according to HSS domains. Then, each group presented their findings, followed by a Q&A session. 5) Advanced group activity – ‘in-depth investigation report’ During the ECE, each group was free to choose, research, and present a topic of interest. 5. Course evaluation methods 1) The Scale of Systems Thinking The scale of Systems Thinking is a previously developed questionnaire[13] embedded in the Pusan National University Learning Management System (LMS). The questionnaire was anonymous, and the students used nicknames to track changes over time (Weeks 1, 6, and 15). The scale comprised 20 items on a 5-point Likert scale categorized into five sub-factors: mental model, individual skill, team activity, systems thinking, and shared vision. 2) Self-assessment of the habits of a systems thinker We explained the 14 Habits of a Systems Thinker (Skochelak, Hammoud et al. 2021) presented by the Waters Center for Systems Thinking to the participants. We asked them to rate their competence on a 5-point Likert scale for each item. This questionnaire was embedded in the Pusan National University LMS, and a similar method was used to maintain anonymity and track changes[14]. The 14 habits are as follows: “H1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system’s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation”[14]. 3) Early clinical exposure report We analyzed reports systematically summarizing observations made during ECE at each KM clinic according to HSS core domains. The researchers extracted meaningful insights from 10 reports and categorized them according to HSS domains using thematic analysis[15, 16]. 4) In-depth investigation report Reports containing detailed investigations on topics of group interest were analyzed and presented. Meaningful insights were extracted and categorized according to HSS domains using thematic analysis. 5) Course evaluation survey of the clinical supervisors After completing the students' field study, a survey was administered to the supervising KMD to assess the program’s effectiveness. The survey inquired about the program’s perceived effectiveness in the seven core domains, four foundational competencies domains, and one linking HSS domain. Responses were collected using a 5-point Likert scale. 6) Course evaluation by students End-of-term course evaluation scores were analyzed. The evaluation results for this course were compared with average college scores. 7) Statistical analysis The survey results were statistically analyzed using descriptive and inferential statistics to evaluate the effects before and after the educational intervention. Descriptive statistics are presented as means and standard deviations. Due to the small sample size, pre- and post-comparisons were performed using non-parametric tests, specifically the Wilcoxon signed-rank test. All statistical analyses were performed using the IBM statistical package for social sciences version 29. Discussion In this study, the HSS course supplied the basic concept through minimal lectures and primarily implemented ECE and group activities. After evaluation, this program improved systems thinking competency and engaged students. Regarding the SST and 14-HST results, the understanding of time flow increased notably. Over four weeks, the students were asked to visit a clinic at the same time; observing the follow-up process of patients proved beneficial in monitoring changes over time. During the final patient interviews which primarily focused on patients with chronic diseases, the patients discussed their journey from the treatment onset to the present. This likely influenced our results [ 17 ]. Recognizing that mental models affect the perception of reality was noted in the 14-HST. However, in the SST, only systems thinking and team learning increased, with a lesser increase in mental models, personal mastery, and shared vision. Unlike the 14-HST, which recognizes the importance of mental models, the SST assesses the actual state of mental models. The students were trained to view phenomena systemically (considering the big picture and changes over time), but more time and training were required to change their mindset (mental model). Personal mastery questions inquiring if one consistently behaved in a systems thinking manner indicated that such foundational mindsets and daily life skills were insufficiently impacted by a semester-long, once-weekly class [ 18 ]. Of the 14-HST, recognizing the impact of time delays on cause-and-effect relationships (H13) had the most significant improvement, indicating that various outcomes can arise depending on the time elapsed between the cause and effect. Identifying leverage actions (H10) and seeking the most effective solutions based on the underlying system using an understanding of the system structure improved significantly. Considering mental models’ effect on the present and future (H9), considering both short- and long-term consequences (H11), and understanding the big picture (H1) also improved considerably. This suggests that the students were trained to examine phenomena from a broader perspective and consider the underlying systems. In contrast, identifying the circular nature of complex cause-and-effect relationships (H4) improved the least. Understanding whether the results can occur cyclically is a relatively challenging concept [ 19 ]. The group activities showed that the students were interested in various HSS domains and had experienced and considered them. Specifically, four domains were highlighted: (1) healthcare structure and processes, (2) healthcare policy and economics, (3) clinical informatics and health technologies, and (4) healthcare value. First, in healthcare structure and processes, difficulties in healthcare delivery systems focused on where referrals from KM clinics to higher-level medical institutions tended to be seen as treatment failure rather than continuity of care. Moreover, there are no tertiary medical institutions in the KM clinics. It is essential to consider the role of KM clinics within the healthcare delivery system and its benefit to society, involving input from patients, healthcare providers, medical educators, and policymakers. Second, regarding policy and economics, the diseases included in the collaborative care pilot project were based on previous evaluations of the effectiveness of collaborative care. The ‘Senior fixed-rate system’ aimed to reduce the burden of medical expenses for the elderly but it has led to a reluctance among seniors to seek treatments that exceed the fixed rate. Third, regarding clinical informatics and health technologies, in-depth investigation topics frequently involved medical informatics and technology, likely reflecting third-year students' efforts to understand KM using their existing scientific knowledge. Early clinical exposure appears to connect prior and subsequent learning effectively. A notable frustration was the limited public knowledge of scientific advancements in KM. In addition, the students were familiar with utilizing information technology as a clinical tool, such as using AI chatbots for clinic promotion or setting effective keywords for patient searches. Fourth, regarding the healthcare value, a notable observation was the application of disposable cups in cupping therapy in Korea, an advanced form of infection prevention. Korean cupping devices, which allow easy and minimal pain removal, have been standardized to minimize patient discomfort and risk of injury. In summary, the students showed significant interest in patient-family-community dynamics, structure and process, informatics, and technology. There has been relatively less focus on system improvements. Most of all, the students had opportunities to think about the relationships between diverse domains and understand that many factors other than the ‘disease itself’ are involved in patient’s health care. In HSS, it is essential to recognize each system and understand their interconnections and cycles [ 20 ]. Systems thinking is an essential competency for future KMDs and is expected to be the basis for learning in various fields in the future[ 21 , 22 ]. Based on the program evaluation performed by students and clinical supervisors, the program needed more system improvement education, as students did not experience problem solving. In external medical institutions, providing problem-solving experiences can be beneficial, although challenging. Exploring such activities in university-affiliated KM hospitals or simulating problem-solving activities through project-based learning may be feasible. In addition, issues have been raised regarding the differences in medical education between university-affiliated hospitals and primary care facilities. Notably, most KM practitioners work in primary care facilities without specialist training, and university hospitals are secondary medical institutions. Therefore, the ECE program focused on primary care institutions that students found more relevant and interesting because of similarities in their future careers. This course teaches HSS using ECE so that students’ observations and experiences can provide a clear and structured understanding of HSS realistically. The ECE was favored by students in this course. Younger students find it challenging to appreciate the connection between humanities and social medicine and clinical medicine, resulting in lower motivation for these subjects [ 23 – 25 ]. This study revealed that ECE effectively demonstrates the relevance of these areas. In addition, observing the daily activities of clinic directors provides insights into KM practitioners’ roles in patient-staff interactions. Interviews with practitioners highlighted lifelong learning through weekend conferences and study sessions, emphasizing continuous self-improvement. Group presentations enabled students to learn about different clinical practices, aiding in career exploration by understanding the strengths of diverse characteristics, including sex, age, and practitioners’ previous careers. However, this study had some limitations. Competencies in medical humanities and social medicine should be continuously cultivated and not concluded after a single semester of learning. This study reports on the effects of a one-semester course. However, it does not evaluate whether student interest, specifically their awareness of the importance of humanities and social sciences, persists during the study of clinical subjects and beyond. Future studies could examine the perceived importance of the HSS core domains specialized fields. Previously, students tended to view subjects such as statistics, humanities, and policy as unrelated to their major compared to direct disease treatment. The presentation outcomes showed the students’ interest in these areas and their relevance to patient care and future medical practice, and quantifying them would be beneficial. Conclusions ECE is an effective method for teaching HSS. A semester-long lecture and practicum on HSS can broaden students’ perspectives on phenomena and cultivate a long-term vision among them. Additional research on the duration and education methods is necessary to ensure sufficient learning of unique concepts, such as system improvement and the understanding of cyclic structures within systems. Moreover, diverse approaches and studies are required to explore methods for introducing HSS. Abbreviations AI, Artificial Intelligence EMR, Electronic Medical Record HSS, Health Systems Sciences KM, Korean Medicine LMS, Learning Management System Declarations Ethics approval and consent to participate The Pusan National University Institutional Review Board approved this study, and written informed consent was obtained from all participants. Consent for publication Not applicable Data availability All data are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interest. Funding This study was supported by Biomedical Research Institute Grant (20220037001), Pusan National University Hospital. Author contributions SI conceived the research question and administered all the processes for this study. HYL analyzed the data and wrote the manuscript. SWS devised the technical methods for the study and critically reviewed the manuscript. JAK formally explained the study and obtained informed consent from the participants. JMS reviewed the draft manuscript. Acknowledgments Not applicable References Smydra R, May M, Taranikanti V, Mi M. Integration of Arts and Humanities in Medical Education: a Narrative Review. J Cancer Educ. 2022;37(5):1267–74. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355(13):1339–44. Boudreau JD, Fuks A. The Humanities in Medical Education: Ways of Knowing, Doing and Being. J Med Humanit. 2015;36(4):321–36. Rabinowitz DG. On the arts and humanities in medical education. Philos Ethics Humanit Med. 2021;16(1):4. Petrou L, Mittelman E, Osibona O, Panahi M, Harvey JM, Patrick YAA, Leedham-Green KE. The role of humanities in the medical curriculum: medical students’ perspectives. BMC Med Educ. 2021;21(1):179. Jeon WT. Health Systems Science. Korean Med Educ Rev. 2018;20(1):60–1. Ryu J-s, Lim B-m, Cho B-M, Lee W-c. 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Perception of Medical Humanities among Polish Medical students: qualitative analysis. Int J Environ Res Public Health. 2022;20(1):270. Kumagai AK. Beyond Dr. feel-good: a role for the humanities in medical education. Acad Med. 2017;92(12):1659–60. Tables Table 1. The scale of systems thinking (n=14, mean (SD)) Week 1 Week 6 Week 15 p-value a p-value b Systems Thinking 3.6 (0.5) 3.7 (0.5) 4.2 (0.5) .642 .017* Mental Model 3.8 (0.6) 3.8 (0.5) 4 (0.5) .858 .163 Personal Mastery 4.1 (0.4) 4 (0.6) 4.2 (0.4) .258 .787 Shared vision 3.9 (0.8) 3.9 (0.7) 4.2 (0.6) .675 .245 Team Learning 3.4 (0.6) 3.4 (0.6) 3.8 (0.8) .784 .028* Total (average) 3.8 (0.4) 3.8 (0.5) 4.1 (0.4) .391 .019* p-value derived by Wilcoxon Signed-Rank test *, p-value <0.05 a Changes between weeks 6 and 1; b Changes between weeks 15 and 1. Table 2. Self-assessment of a systems thinker’s habits Week 1 Week 6 Week 15 p-value a p-value b H1 3.9 (0.8) 3.8 (0.9) 4.4 (0.7) .763 .035* H2 3.6 (1) 3.9 (0.7) 4.3 (0.5) .334 .047* H3 3.6 (0.9) 3.8 (0.6) 4.0 (0.7) .527 .059 H4 3.6 (0.9) 3.8 (0.8) 3.9 (0.9) .480 .317 H5 3.6 (1) 3.7 (1) 4.1 (0.9) .680 .159 H6 3.7 (1) 3.8 (1) 4.1 (0.7) .914 .063 H7 3.4 (1.1) 3.6 (1) 3.9 (0.9) .234 .107 H8 3.8 (0.9) 3.9 (0.9) 4.4 (0.8) .706 .118 H9 3.2 (0.8) 3.6 (0.8) 3.9 (0.7) .160 .026* H10 3.4 (0.9) 3.2 (0.9) 4.1 (0.7) .558 .014* H11 3.5 (1) 3.5 (1.1) 4.4 (0.6) .957 .010* H12 3.8 (0.8) 3.6 (0.5) 4.1 (0.8) .527 .059 H13 3.2 (0.9) 3.3 (0.7) 4.3 (0.5) .739 .004* H14 4.1 (1) 4 (0.7) 4.6 (0.6) .730 .020* Total (average) 3.6 (0.5) 3.7 (0.5) 4.2 (0.5) .593 .002* p-value derived by Wilcoxon Signed-Rank test *, p-value <0.05 a Changes between weeks 6 and 1; b Changes between weeks 15 and 1. H1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system’s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation Table 3. Health Systems Science core functional domains and students’ learning activities Domains Early clinical exposure report In-depth investigation report Patients, family, and community • Visited upon recommendation from an acquaintance. • Daughter came for treatment, previously accompanying father. • Aspiring compassionate doctor who cares for patients in traditional Korean medicine. • Roles patients expect from a Korean medicine clinic (consultation, lifestyle management, and initial herbal treatments). • Based on lumbar disc herniation patient's occupation, environment, and lifestyle management. • Factors contributing to patient satisfaction • Patients' expectations and traditional knowledge explanations (e.g., pulse diagnosis). Health care structure and process • Diagnosis process within the clinic. • Differences between clinic-level and hospital-level medical institutions. • Role and challenges in healthcare delivery systems. • Differences between Korean medicine clinics and hospitals • Roles and challenges in healthcare delivery systems. Health care policy and economics • Elderly fixed payment system, collaborative pilot projects, contract practice pilot projects, and home visit pilot projects. • Automobile insurance, indemnity insurance, and other reimbursement methods. • Collaboration pilot projects. • Relationship between health insurance and medical use. • Insurance coverage of acupuncture treatments. Clinical informatics and health technology • Use of EMR, HIRA electronic claims, research and writing, questionnaires, scales, and clinical guidelines. • Types, ingredients, effects, and side effects of acupuncture treatments. • Mechanisms of cupping and bloodletting therapies. • Clinical guidelines. • AI chatbot usage for counseling and marketing in Korean medicine clinics. • Custom keyword settings for Korean medicine clinic promotion. Population, public, and social determinants of health • Regional characteristics. • Differences in health status based on patient's occupation and socioeconomic status. • Occupational guidance. • Major treatment subjects depending on Korean medicine clinic location. Value in health care • Measures for preventing accidents. • Waste disposal, safe bedding, and prevention of abrasions/falls/infections. • International standardization of cupping therapy for patient safety. Health system improvement • Intra/extra system improvement activities. • Attendance at conferences and lifelong learning. • Treatment room structure for privacy protection. • Management and marketing (AI chatbot usage). AI, artificial intelligence; EMR, Electronic Medical Record; HIRA, Health Insurance Review & Assessment Service; Table 4. Effectiveness of this course to educate each domain of HSS (by clinical supervisors, n=10) Category mean SD Domains mean SD Core functional domains 4.2 0.6 Patients, family, and community 4.5 0.5 Health care structure and process 4.6 0.5 Health care policy and economics 4.0 0.8 Clinical informatics and health technology 4.1 0.8 Population, public, and social determinants of health 4.0 0.8 value in health care 4.1 0.7 Health system improvement 3.9 0.7 Foundational domains 4.1 0.7 Change agency, management, and advocacy 4.1 0.7 Ethics and legal 4.1 0.8 Leadership 4.2 0.9 Teaming 4.1 0.7 Linking domain 4.2 0.9 Systems thinking 4.2 0.9 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 23 Aug, 2024 Editor assigned by journal 21 Aug, 2024 Submission checks completed at journal 21 Aug, 2024 First submitted to journal 19 Aug, 2024 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-4941094","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344167082,"identity":"749b5045-1d78-429e-af73-fed572c971d1","order_by":0,"name":"Hye-Yoon Lee","email":"","orcid":"","institution":"Pusan National University School of Korean Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hye-Yoon","middleName":"","lastName":"Lee","suffix":""},{"id":344167083,"identity":"fda3591f-0df0-4681-8213-18ddbba294d1","order_by":1,"name":"Sunju Im","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYJACAyDkYWPvAXN4+IjVIsPHcwaihQ1EHiBCm42cRA6ERVCL/IzcA8U8Bdt42CTfHvxcmGMnw8bAe/DxB3yOupGXYMxjcJuHTTovWXrmtmSgw/iSDfDZYiCRYwDVkmMgzbuNGaiFx0wCv8NgWiTPGP/m3VYP0mL+A58WhhswLRI8ZkBbDoNtwet9gzNvDAzngLTw5JhZ8247zsPGzGMscQafw9pzzAze/LltL99+xvg277Zqe372HsMPFfgcBowIA1Q+M37lYCUPCKsZBaNgFIyCEQ0AosI8+KY+wBQAAAAASUVORK5CYII=","orcid":"","institution":"Pusan National University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sunju","middleName":"","lastName":"Im","suffix":""},{"id":344167084,"identity":"9fc5d383-616f-44fc-80fa-a28e991e23c2","order_by":2,"name":"Sang-Won Shin","email":"","orcid":"","institution":"Pusan National University School of Korean Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sang-Won","middleName":"","lastName":"Shin","suffix":""},{"id":344167085,"identity":"8fb61f0c-5beb-4d91-8a2e-bf2f1c2effef","order_by":3,"name":"Jung-Ae Kim","email":"","orcid":"","institution":"Pusan National University School of Korean Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jung-Ae","middleName":"","lastName":"Kim","suffix":""},{"id":344167086,"identity":"cec27a98-991c-4e0b-bd1f-54dfb6fb11d5","order_by":4,"name":"Jin-Mi Song","email":"","orcid":"","institution":"Pusan National University School of Korean Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jin-Mi","middleName":"","lastName":"Song","suffix":""}],"badges":[],"createdAt":"2024-08-20 00:29:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4941094/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4941094/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08250-z","type":"published","date":"2025-12-26T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66670987,"identity":"b26ce83e-a22e-485e-b50f-ab762ffed6cf","added_by":"auto","created_at":"2024-10-15 10:25:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25136,"visible":true,"origin":"","legend":"\u003cp\u003eThe flow diagram of the course and the evaluation\u003c/p\u003e\n\u003cp\u003eECE, early clinical exposure (1week for preparations and 4weeks in the field); CE, course evaluation.\u003c/p\u003e\n\u003cp\u003e‘Questionnaires’ includes\u003c/p\u003e\n\u003cp\u003e‘Group activities’ indicates the basic and advanced group activities.\u003c/p\u003e\n\u003cp\u003e‘Group reports’ indicates the early clinical exposure and in-depth investigation reports.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4941094/v1/fb52242cea69e0d8ee6d6918.png"},{"id":66670986,"identity":"f20cd9a2-61fe-4208-944d-709c185c6ca1","added_by":"auto","created_at":"2024-10-15 10:25:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":8680,"visible":true,"origin":"","legend":"\u003cp\u003eThe end-term course evaluation results by students\u003c/p\u003e\n\u003cp\u003eFor better readability, the graph starts from a score of 4.5.\u003c/p\u003e\n\u003cp\u003eQ1: Course Structure (syllabus); Q2, Teaching Methods; Q3, Instructional Expertise; Q4, Assignments (feedback); Q5, Evaluation Criteria; Q6, Effectiveness; Q7, Satisfaction.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4941094/v1/5f01048a1d3b7eb51602c155.png"},{"id":99172271,"identity":"8621324c-e3fb-4dbc-9493-a50287edf518","added_by":"auto","created_at":"2025-12-29 16:06:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":596336,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4941094/v1/59692657-2a8c-4dbd-9d0e-43d9c627bb44.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe medical education curriculum comprises basic and clinical medicine as well as medical humanities and social medicine disciplines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Medical humanities and social medicine gained prominence later than basic and clinical medicine, as the limitations of the Flexner\u0026rsquo;s model became apparent, highlighting the need for a holistic approach to medical education [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Medical humanities and social medicine comprise several disciplines, such as history, philosophy, ethics, law, religion, and social policy. Health Systems Science (HSS) focuses on the healthcare system within the medical humanities and social medicine domains [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. HSS provides a comprehensive understanding of the interrelated factors that influence patient health, with the ultimate goal of providing patient-centered medicine. It is more practical and realistic compared to traditional medical humanities and social medicine domains [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHSS addresses the impact of various factors, including healthcare policy, economics, and structure, on patient health status and healthcare experiences. The dualized healthcare system in Korea, which integrates conventional and Korean medicine (KM), is unique because it offers patients more options. However, it has been criticized for escalating medical costs and causing conflicts among medical professionals[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This healthcare system requires professionals\u0026rsquo; attention to social aspects beyond clinical practice. HSS is considered more suitable for the four-year medical school program because its scope is narrower and more focused. In contrast, the \u0026lsquo;humanities and social medicine\u0026rsquo; concept is deemed more appropriate for the six-year medical college curriculum because it encompasses broader areas, including liberal arts[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. South Korea has four- and six-year educational programs. The six-year program, which comprised two-year pre-medical and four-year medical courses, has been reformed into a single six-year program. In addition, the South Korean university curricula are categorized into major-required courses and general education courses, with students demonstrating significantly different attitudes towards mandatory courses than general education courses. Considering these factors, it is essential to evaluate which is more suitable between HSS and the humanities and social medicine framework, or whether combining both should be considered.\u003c/p\u003e \u003cp\u003eIn addition, students tend to show low interest in humanities and social medicine and regard these subjects as unrelated to their primary studies[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, it is essential to identify appropriate teaching methods for HSS. Early clinical exposure (ECE) refers to exposure to clinical settings in hospitals and the community before the clinical phase, to help students learn about clinical science[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In addition, frequent exposure to medical practice increases the understanding of the medical field and empathy for patients' suffering[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we aimed to introduce HSS into Korean medical education and evaluate its satisfaction and effectiveness.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis prospective observational study collected students\u0026rsquo; responses to questionnaires on the study\u0026rsquo;s purpose and analyzed the outcomes of the course, including the reaction and learning. The Pusan National University Institutional Review Board approved this study (No.2023-150-HR).\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSubjects\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAll third-year undergraduate students (n\u0026thinsp;=\u0026thinsp;21) in the integrated bachelor\u0026rsquo;s master\u0026rsquo;s (3\u0026thinsp;+\u0026thinsp;4) program undertook the course in the second semester of 2023. The students studied basic biomedical sciences and basic liberal arts before taking any clinical course.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eConsent and recruitment for the questionnaires\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e The questionnaires were administered to only participants who submitted written informed consent. Information regarding study participation was posted on a website and social media. Interested students were provided with written explanations. They were given opportunities to ask questions, after which the students who voluntarily agreed to participate signed a written consent form. The surveys were anonymous and collected no personal information. Participants tracked changes using self-chosen nicknames.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTeaching methods (activities during this course)\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLectures\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe lectures explained the concept of HSS core functional, foundational, and linking domains, highlighting that HSS is the third pillar of medical education in basic and clinical sciences. The lectures were delivered by three professors: (1) a medical doctor and a medical education expert, (2) a Korean medical doctor (KMD) and expert in classics in Korean medicine, and (3) a KMD (specialist in Korean internal medicine) and expert in medical education.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCase-based discussion\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe professors developed cases illustrating the complex interrelationships between various domains within HSS. During class, the students analyzed the underlying HSS domains of each case and systematically approached solutions using the think-pair-share method. Below are the case examples used in the discussion:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLet us consider the causes and solutions for a 46-year-old male patient with obesity.\u003c/p\u003e\u003cp\u003eLet us consider the causes and prevention methods of incidents where acupuncture needles are unintentionally left in a patient\u0026rsquo;s body after treatment at a KM clinic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEarly clinical exposure\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWe formed 10 groups comprising nine duos and one trio and assigned each group to a KM clinic based on their preferences. Over four consecutive weeks, the students visited their designated clinic once weekly for 3 h over. During their visits, the students interviewed the patients, focusing on the interconnections between HSS domains.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBasic group activity \u0026ndash; \u0026lsquo;early clinical exposure report\u0026rsquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAfter completing 4-weeks of ECE training, the students systematically analyzed their observations according to HSS domains. Then, each group presented their findings, followed by a Q\u0026amp;A session.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdvanced group activity \u0026ndash; \u0026lsquo;in-depth investigation report\u0026rsquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDuring the ECE, each group was free to choose, research, and present a topic of interest.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCourse evaluation methods\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe Scale of Systems Thinking\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe scale of Systems Thinking is a previously developed questionnaire[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] embedded in the Pusan National University Learning Management System (LMS). The questionnaire was anonymous, and the students used nicknames to track changes over time (Weeks 1, 6, and 15). The scale comprised 20 items on a 5-point Likert scale categorized into five sub-factors: mental model, individual skill, team activity, systems thinking, and shared vision.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSelf-assessment of the habits of a systems thinker\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWe explained the 14 Habits of a Systems Thinker (Skochelak, Hammoud et al. 2021) presented by the Waters Center for Systems Thinking to the participants. We asked them to rate their competence on a 5-point Likert scale for each item. This questionnaire was embedded in the Pusan National University LMS, and a similar method was used to maintain anonymity and track changes[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 14 habits are as follows: \u0026ldquo;H1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system\u0026rsquo;s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation\u0026rdquo;[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEarly clinical exposure report\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWe analyzed reports systematically summarizing observations made during ECE at each KM clinic according to HSS core domains. The researchers extracted meaningful insights from 10 reports and categorized them according to HSS domains using thematic analysis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn-depth investigation report\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eReports containing detailed investigations on topics of group interest were analyzed and presented. Meaningful insights were extracted and categorized according to HSS domains using thematic analysis.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCourse evaluation survey of the clinical supervisors\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAfter completing the students' field study, a survey was administered to the supervising KMD to assess the program\u0026rsquo;s effectiveness. The survey inquired about the program\u0026rsquo;s perceived effectiveness in the seven core domains, four foundational competencies domains, and one linking HSS domain. Responses were collected using a 5-point Likert scale.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCourse evaluation by students\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEnd-of-term course evaluation scores were analyzed. The evaluation results for this course were compared with average college scores.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e7) Statistical analysis\u003c/h2\u003e \u003cp\u003eThe survey results were statistically analyzed using descriptive and inferential statistics to evaluate the effects before and after the educational intervention. Descriptive statistics are presented as means and standard deviations. Due to the small sample size, pre- and post-comparisons were performed using non-parametric tests, specifically the Wilcoxon signed-rank test. All statistical analyses were performed using the IBM statistical package for social sciences version 29.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Study design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis prospective observational study collected students’ responses to questionnaires on the study’s purpose and analyzed the outcomes of the course, including the reaction and learning. The Pusan National University Institutional Review Board approved this study (No.2023-150-HR).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Subjects\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll third-year undergraduate students (n=21) in the integrated bachelor’s master’s (3+4) program undertook the course in the second semester of 2023. The students studied basic biomedical sciences and basic liberal arts before taking any clinical course.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Consent and recruitment for the questionnaires\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe questionnaires were administered to only participants who submitted written informed consent. Information regarding study participation was posted on a website and social media. Interested students were provided with written explanations. They were given opportunities to ask questions, after which the students who voluntarily agreed to participate signed a written consent form. The surveys were anonymous and collected no personal information. Participants tracked changes using self-chosen nicknames.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;Teaching methods (activities during this course)\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp; \u0026nbsp;Lectures \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe lectures explained the concept of HSS core functional, foundational, and linking domains, highlighting that HSS is the third pillar of medical education in basic and clinical sciences. The lectures were delivered by three professors: (1) a medical doctor and a medical education expert, (2) a Korean medical doctor (KMD) and expert in classics in Korean medicine, and (3) a KMD (specialist in Korean internal medicine) and expert in medical education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp; \u0026nbsp;Case-based discussion\u003c/p\u003e\n\u003cp\u003eThe professors developed cases illustrating the complex interrelationships between various domains within HSS. During class, the students analyzed the underlying HSS domains of each case and systematically approached solutions using the think-pair-share method. Below are the case examples used in the discussion:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“Let us consider the causes and solutions for a 46-year-old male patient with obesity.”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“Let us consider the causes and prevention methods of incidents where acupuncture needles are unintentionally left in a patient’s body after treatment at a KM clinic.” \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp; \u0026nbsp;Early clinical exposure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe formed 10 groups comprising nine duos and one trio and assigned each group to a KM clinic based on their preferences. Over four consecutive weeks, the students visited their designated clinic once weekly for 3 h over. During their visits, the students interviewed the patients, focusing on the interconnections between HSS domains.\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp; \u0026nbsp;Basic group activity – ‘early clinical exposure report’\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter completing 4-weeks of ECE training, the students systematically analyzed their observations according to HSS domains. Then, each group presented their findings, followed by a Q\u0026amp;A session. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp; \u0026nbsp;Advanced group activity – ‘in-depth investigation report’\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the ECE, each group was free to choose, research, and present a topic of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;Course evaluation methods\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp; \u0026nbsp;The Scale of Systems Thinking \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe scale of Systems Thinking is a previously developed questionnaire[13]\u0026nbsp;embedded in the Pusan National University Learning Management System (LMS). The questionnaire was anonymous, and the students used nicknames to track changes over time (Weeks 1, 6, and 15). The scale comprised 20 items on a 5-point Likert scale categorized into five sub-factors: mental model, individual skill, team activity, systems thinking, and shared vision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp; \u0026nbsp;Self-assessment of the habits of a systems thinker\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe explained the 14 Habits of a Systems Thinker (Skochelak, Hammoud et al. 2021) presented by the Waters Center for Systems Thinking to the participants. We asked them to rate their competence on a 5-point Likert scale for each item. This questionnaire was embedded in the Pusan National University LMS, and a similar method was used to maintain anonymity and track changes[14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 14 habits are as follows: “H1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system’s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation”[14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp; \u0026nbsp;Early clinical exposure report\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe analyzed reports systematically summarizing observations made during ECE at each KM clinic according to HSS core domains. The researchers extracted meaningful insights from 10 reports and categorized them according to HSS domains using thematic analysis[15, 16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp; \u0026nbsp;In-depth investigation report\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReports containing detailed investigations on topics of group interest were analyzed and presented. Meaningful insights were extracted and categorized according to HSS domains using thematic analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp; \u0026nbsp;Course evaluation survey of the clinical supervisors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter completing the students' field study, a survey was administered to the supervising KMD to assess the program’s effectiveness. The survey inquired about the program’s perceived effectiveness in the seven core domains, four foundational competencies domains, and one linking HSS domain. Responses were collected using a 5-point Likert scale.\u003c/p\u003e\n\u003cp\u003e6)\u0026nbsp; \u0026nbsp;Course evaluation by students\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEnd-of-term course evaluation scores were analyzed. The evaluation results for this course were compared with average college scores.\u003c/p\u003e\n\u003cp\u003e7)\u0026nbsp; \u0026nbsp;Statistical analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe survey results were statistically analyzed using descriptive and inferential statistics to evaluate the effects before and after the educational intervention. Descriptive statistics are presented as means and standard deviations. Due to the small sample size, pre- and post-comparisons were performed using non-parametric tests, specifically the Wilcoxon signed-rank test. All statistical analyses were performed using the IBM statistical package for social sciences version 29.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the HSS course supplied the basic concept through minimal lectures and primarily implemented ECE and group activities. After evaluation, this program improved systems thinking competency and engaged students.\u003c/p\u003e \u003cp\u003eRegarding the SST and 14-HST results, the understanding of time flow increased notably. Over four weeks, the students were asked to visit a clinic at the same time; observing the follow-up process of patients proved beneficial in monitoring changes over time. During the final patient interviews which primarily focused on patients with chronic diseases, the patients discussed their journey from the treatment onset to the present. This likely influenced our results [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecognizing that mental models affect the perception of reality was noted in the 14-HST. However, in the SST, only systems thinking and team learning increased, with a lesser increase in mental models, personal mastery, and shared vision. Unlike the 14-HST, which recognizes the importance of mental models, the SST assesses the actual state of mental models. The students were trained to view phenomena systemically (considering the big picture and changes over time), but more time and training were required to change their mindset (mental model). Personal mastery questions inquiring if one consistently behaved in a systems thinking manner indicated that such foundational mindsets and daily life skills were insufficiently impacted by a semester-long, once-weekly class [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf the 14-HST, recognizing the impact of time delays on cause-and-effect relationships (H13) had the most significant improvement, indicating that various outcomes can arise depending on the time elapsed between the cause and effect. Identifying leverage actions (H10) and seeking the most effective solutions based on the underlying system using an understanding of the system structure improved significantly. Considering mental models\u0026rsquo; effect on the present and future (H9), considering both short- and long-term consequences (H11), and understanding the big picture (H1) also improved considerably. This suggests that the students were trained to examine phenomena from a broader perspective and consider the underlying systems. In contrast, identifying the circular nature of complex cause-and-effect relationships (H4) improved the least. Understanding whether the results can occur cyclically is a relatively challenging concept [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe group activities showed that the students were interested in various HSS domains and had experienced and considered them. Specifically, four domains were highlighted: (1) healthcare structure and processes, (2) healthcare policy and economics, (3) clinical informatics and health technologies, and (4) healthcare value. First, in healthcare structure and processes, difficulties in healthcare delivery systems focused on where referrals from KM clinics to higher-level medical institutions tended to be seen as treatment failure rather than continuity of care. Moreover, there are no tertiary medical institutions in the KM clinics. It is essential to consider the role of KM clinics within the healthcare delivery system and its benefit to society, involving input from patients, healthcare providers, medical educators, and policymakers. Second, regarding policy and economics, the diseases included in the collaborative care pilot project were based on previous evaluations of the effectiveness of collaborative care. The \u0026lsquo;Senior fixed-rate system\u0026rsquo; aimed to reduce the burden of medical expenses for the elderly but it has led to a reluctance among seniors to seek treatments that exceed the fixed rate. Third, regarding clinical informatics and health technologies, in-depth investigation topics frequently involved medical informatics and technology, likely reflecting third-year students' efforts to understand KM using their existing scientific knowledge. Early clinical exposure appears to connect prior and subsequent learning effectively. A notable frustration was the limited public knowledge of scientific advancements in KM. In addition, the students were familiar with utilizing information technology as a clinical tool, such as using AI chatbots for clinic promotion or setting effective keywords for patient searches. Fourth, regarding the healthcare value, a notable observation was the application of disposable cups in cupping therapy in Korea, an advanced form of infection prevention. Korean cupping devices, which allow easy and minimal pain removal, have been standardized to minimize patient discomfort and risk of injury. In summary, the students showed significant interest in patient-family-community dynamics, structure and process, informatics, and technology. There has been relatively less focus on system improvements. Most of all, the students had opportunities to think about the relationships between diverse domains and understand that many factors other than the \u0026lsquo;disease itself\u0026rsquo; are involved in patient\u0026rsquo;s health care. In HSS, it is essential to recognize each system and understand their interconnections and cycles [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Systems thinking is an essential competency for future KMDs and is expected to be the basis for learning in various fields in the future[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the program evaluation performed by students and clinical supervisors, the program needed more system improvement education, as students did not experience problem solving. In external medical institutions, providing problem-solving experiences can be beneficial, although challenging. Exploring such activities in university-affiliated KM hospitals or simulating problem-solving activities through project-based learning may be feasible. In addition, issues have been raised regarding the differences in medical education between university-affiliated hospitals and primary care facilities. Notably, most KM practitioners work in primary care facilities without specialist training, and university hospitals are secondary medical institutions. Therefore, the ECE program focused on primary care institutions that students found more relevant and interesting because of similarities in their future careers.\u003c/p\u003e \u003cp\u003eThis course teaches HSS using ECE so that students\u0026rsquo; observations and experiences can provide a clear and structured understanding of HSS realistically. The ECE was favored by students in this course. Younger students find it challenging to appreciate the connection between humanities and social medicine and clinical medicine, resulting in lower motivation for these subjects [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This study revealed that ECE effectively demonstrates the relevance of these areas. In addition, observing the daily activities of clinic directors provides insights into KM practitioners\u0026rsquo; roles in patient-staff interactions. Interviews with practitioners highlighted lifelong learning through weekend conferences and study sessions, emphasizing continuous self-improvement. Group presentations enabled students to learn about different clinical practices, aiding in career exploration by understanding the strengths of diverse characteristics, including sex, age, and practitioners\u0026rsquo; previous careers.\u003c/p\u003e \u003cp\u003eHowever, this study had some limitations. Competencies in medical humanities and social medicine should be continuously cultivated and not concluded after a single semester of learning. This study reports on the effects of a one-semester course. However, it does not evaluate whether student interest, specifically their awareness of the importance of humanities and social sciences, persists during the study of clinical subjects and beyond. Future studies could examine the perceived importance of the HSS core domains specialized fields. Previously, students tended to view subjects such as statistics, humanities, and policy as unrelated to their major compared to direct disease treatment. The presentation outcomes showed the students\u0026rsquo; interest in these areas and their relevance to patient care and future medical practice, and quantifying them would be beneficial.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eECE is an effective method for teaching HSS. A semester-long lecture and practicum on HSS can broaden students\u0026rsquo; perspectives on phenomena and cultivate a long-term vision among them. Additional research on the duration and education methods is necessary to ensure sufficient learning of unique concepts, such as system improvement and the understanding of cyclic structures within systems. Moreover, diverse approaches and studies are required to explore methods for introducing HSS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAI, Artificial Intelligence\u003c/p\u003e\n\u003cp\u003eEMR, Electronic Medical Record\u003c/p\u003e\n\u003cp\u003eHSS, Health Systems Sciences\u003c/p\u003e\n\u003cp\u003eKM, Korean Medicine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMS, Learning Management System\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe Pusan National University Institutional Review Board approved this study, and written informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eAll data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by Biomedical Research Institute Grant (20220037001), Pusan National University Hospital.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eSI conceived the research question and administered all the processes for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHYL analyzed the data and wrote the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSWS devised the technical methods for the study and critically reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJAK formally explained the study and obtained informed consent from the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJMS reviewed the draft manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSmydra R, May M, Taranikanti V, Mi M. Integration of Arts and Humanities in Medical Education: a Narrative Review. J Cancer Educ. 2022;37(5):1267\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355(13):1339\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoudreau JD, Fuks A. The Humanities in Medical Education: Ways of Knowing, Doing and Being. J Med Humanit. 2015;36(4):321\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabinowitz DG. On the arts and humanities in medical education. Philos Ethics Humanit Med. 2021;16(1):4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetrou L, Mittelman E, Osibona O, Panahi M, Harvey JM, Patrick YAA, Leedham-Green KE. The role of humanities in the medical curriculum: medical students\u0026rsquo; perspectives. BMC Med Educ. 2021;21(1):179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon WT. Health Systems Science. Korean Med Educ Rev. 2018;20(1):60\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyu J-s, Lim B-m, Cho B-M, Lee W-c. Yoon T-h: Consciousness on co-operative practices between doctors who working in cooperative practicing hospitals and general hospital. J Soc Prev Korean Med. 2009;13(3):29\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeong I-S, Kim Y-J, Lee W-C. Utilization and attitude toward the East-West collaborative medical practices among healthcare consumers. J Soc Prev Korean Med. 2010;14(2):43\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim T. Introduction of America's Health Systems Science Education and Its Criticism. Uisahak. 2022;31(3):519\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAxelrod C, Brenna CT, Gershon A, Peterkin A, Nyhof-Young J. The Companion Curriculum: medical students\u0026rsquo; perceptions of the integration of humanities within medical education. Can Med Educ J. 2023;14(2):119\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaşak O, Yaphe J, Spiegel W, Wilm S, Carelli F, Metsemakers JF. Early clinical exposure in medical curricula across Europe: an overview. Eur J Gen Pract. 2009;15(1):4\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLittlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: systematic review. BMJ. 2005;331(7513):387\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Kwon H, Park K, Lee H. An instrument development and validation for measuring high school students' systems thinking. J Korean association Sci Educ. 2013;33(5):995\u0026ndash;1006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkochelak SE, Hammoud MM, Lommis KD, Borkan JM, Gonzalo JD, Lawson LE, Starr SR. AMA Education Sonsortium Health Systems Science, Second edn. Philadelphia: Elsevier; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: Striving to meet the trustworthiness criteria. Int J qualitative methods. 2017;16(1):1609406917733847.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonnie LHA, Cremers GR, Nasori M, Kramer AWM, van Dijk N. Longitudinal training models for entrusting students with independent patient care? A systematic review. Med Educ. 2022;56(2):159\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark K, Hoffman A. Educating healthcare students: Strategies to teach systems thinking to prepare new healthcare graduates. J Prof Nurs. 2019;35(3):195\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNa S-H. Development and Implementation of Health Systems Science Education in the Clinical Learning Environment. Korean Med Educ Rev. 2023;25(3):229\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGonzalo JD, Chang A, Dekhtyar M, Starr SR, Holmboe E, Wolpaw DR. Health systems science in medical education: unifying the components to catalyze transformation. Acad Med. 2020;95(9):1362\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlack P, Margaret M, Scott R. Systems thinking in the healthcare professions: A guide for educators and clinicians. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD\u0026rsquo;Eon M. Systems thinking and structural competence in and for medical education. Can Med Educ J. 2017;8(1):e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetrou L, Mittelman E, Osibona O, Panahi M, Harvey JM, Patrick YA, Leedham-Green KE. The role of humanities in the medical curriculum: medical students\u0026rsquo; perspectives. BMC Med Educ. 2021;21:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakowska M, Szczepek AJ, Nowosad I, Weissbrot-Koziarska A, Dec-Pietrowska J. Perception of Medical Humanities among Polish Medical students: qualitative analysis. Int J Environ Res Public Health. 2022;20(1):270.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumagai AK. Beyond Dr. feel-good: a role for the humanities in medical education. Acad Med. 2017;92(12):1659\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. The scale of systems thinking (n=14, mean (SD))\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003eSystems Thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.7 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4.2 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003eMental Model\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003ePersonal Mastery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4.2 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003eShared vision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4.2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003eTeam Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.4 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.4 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.028*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.959183673469386%\" valign=\"top\"\u003e\n \u003cp\u003eTotal (average)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.081632653061224%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.10204081632653%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.489795918367347%\" valign=\"top\"\u003e\n \u003cp\u003e.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep-value derived by Wilcoxon Signed-Rank test\u003c/p\u003e\n\u003cp\u003e*, p-value \u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Changes between weeks 6 and 1; \u003csup\u003eb\u003c/sup\u003e Changes between weeks 15 and 1.\u003c/p\u003e\n\u003cp\u003eTable 2. Self-assessment of a systems thinker\u0026rsquo;s habits\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003eWeek 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.4 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.3 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.0 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.527\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.7 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.7 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.4 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.4 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.706\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.2 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.026*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.4 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.2 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.5 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.4 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.010*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.527\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.2 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.3 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.3 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.739\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eH14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.6 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.730\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.742268041237114%\" valign=\"top\"\u003e\n \u003cp\u003eTotal (average)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e3.7 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" valign=\"top\"\u003e\n \u003cp\u003e4.2 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep-value derived by Wilcoxon Signed-Rank test\u003c/p\u003e\n\u003cp\u003e*, p-value \u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Changes between weeks 6 and 1; \u003csup\u003eb\u003c/sup\u003e Changes between weeks 15 and 1.\u003c/p\u003e\n\u003cp\u003eH1, Seeks to understand the big picture; H2, observes how elements within systems change over time, generating patterns and trends; H3, recognizes that a system\u0026rsquo;s structure generates its behavior; H4, identifies the circular nature of complex cause-and-effect relationships; H5, make a meaningful connection within and between systems; H6, Changes perspectives to increase understanding; H7, surfaces and tests assumptions; H8, considers an issue fully and resists the urge to come to a quick conclusion; H9, considers how mental models affect current reality and the future; H10, uses understanding of system structure to identify possible leverage actions; H11, considers short-term, long-term and unintended consequences of actions; H12, pays attention to accumulations and their rates of changes; H13, recognizes the impact of time delays when exploring cause and effect relationships; H14, checks results, and changes actions if needed: successive approximation\u003c/p\u003e\n\u003cp\u003eTable 3. Health Systems Science core functional domains and students\u0026rsquo; learning activities\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly clinical exposure report\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-depth investigation report\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003ePatients, family, and community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Visited upon recommendation from an acquaintance.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Daughter came for treatment, previously accompanying father.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Aspiring compassionate doctor who cares for patients in traditional Korean medicine.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Roles patients expect from a Korean medicine clinic (consultation, lifestyle management, and initial herbal treatments).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Based on lumbar disc herniation patient\u0026apos;s occupation, environment, and lifestyle management.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Factors contributing to patient satisfaction\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patients\u0026apos; expectations and traditional knowledge explanations (e.g., pulse diagnosis).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003eHealth care structure and process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Diagnosis process within the clinic.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Differences between clinic-level and hospital-level medical institutions.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Role and challenges in healthcare delivery systems.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Differences between Korean medicine clinics and hospitals\u003c/p\u003e\n \u003cp\u003e\u0026bull; Roles and challenges in healthcare delivery systems.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003eHealth care policy and economics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Elderly fixed payment system, collaborative pilot projects, contract practice pilot projects, and home visit pilot projects.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Automobile insurance, indemnity insurance, and other reimbursement methods.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Collaboration pilot projects.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Relationship between health insurance and medical use.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Insurance coverage of acupuncture treatments.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003eClinical informatics and health technology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Use of EMR, HIRA electronic claims, research and writing, questionnaires, scales, and clinical guidelines.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Types, ingredients, effects, and side effects of acupuncture treatments.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mechanisms of cupping and bloodletting therapies.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical guidelines.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; AI chatbot usage for counseling and marketing in Korean medicine clinics.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Custom keyword settings for Korean medicine clinic promotion.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003ePopulation, public, and social determinants of health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Regional characteristics.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Differences in health status based on patient\u0026apos;s occupation and socioeconomic status.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational guidance.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Major treatment subjects depending on Korean medicine clinic location.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003eValue in health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Measures for preventing accidents.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Waste disposal, safe bedding, and prevention of abrasions/falls/infections.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; International standardization of cupping therapy for patient safety.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.129783693843596%\" valign=\"top\"\u003e\n \u003cp\u003eHealth system improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.089850249584025%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Intra/extra system improvement activities.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Attendance at conferences and lifelong learning.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Treatment room structure for privacy protection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.78036605657238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Management and marketing (AI chatbot usage).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAI, artificial intelligence; EMR, Electronic Medical Record; HIRA, Health Insurance Review \u0026amp; Assessment Service;\u003c/p\u003e\n\u003cp\u003eTable 4. Effectiveness of this course to educate each domain of HSS (by clinical supervisors, n=10) \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.3156146179402%\" valign=\"top\"\u003e\n \u003cp\u003eDomains\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.777408637873755%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eCore functional domains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.3156146179402%\" valign=\"top\"\u003e\n \u003cp\u003ePatients, family, and community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eHealth care structure and process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eHealth care policy and economics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eClinical informatics and health technology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003ePopulation, public, and social determinants of health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003evalue in health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eHealth system improvement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.777408637873755%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eFoundational domains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.3156146179402%\" valign=\"top\"\u003e\n \u003cp\u003eChange agency, management, and advocacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eEthics and legal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eLeadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.85611510791367%\" valign=\"top\"\u003e\n \u003cp\u003eTeaming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.990407673860911%\" valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.15347721822542%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003eLinking domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.3156146179402%\" valign=\"top\"\u003e\n \u003cp\u003eSystems thinking\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.305647840531561%\" valign=\"top\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.647840531561462%\" valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"Health systems science, early clinical exposure, Korean medicine, medical humanities and social medicine","lastPublishedDoi":"10.21203/rs.3.rs-4941094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4941094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth professions are required to understand social structures and systems, as well as basic and clinical medical knowledge. Accordingly, Health Systems Science (HSS) is recognized as a third party of medical education. The curriculum for HSS is currently being developed and implemented in Korea. This study aimed to evaluate the effectiveness of HSS in Korean medical education.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe HSS course using early clinical exposure (ECE) was implemented in Korean medical education and comprised lectures, four ECEs, and group activities. Students and clinical directors evaluated the course using questionnaires focused on systems thinking, productivity of group activities, and satisfaction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study showed significant improvements in systems thinking, especially in team learning (p\u0026thinsp;=\u0026thinsp;.028) and overall systems thinking (p\u0026thinsp;=\u0026thinsp;.017). Key habits related to systems thinking also improved significantly over 15 weeks. ECE reports highlighted student engagement with various HSS domains, focusing on patient care, healthcare structure, and policy. Per the clinical directors\u0026rsquo; evaluations, \u0026ldquo;healthcare structure and process\u0026rdquo; was the most effective domain among the core domains of HSS. Per the students\u0026rsquo; evaluations, the overall satisfaction was higher than the college\u0026rsquo;s average score, and especially \u0026ldquo;course structure\u0026rdquo; and \u0026ldquo;instructional expertise\u0026rdquo; domains were rated most effective.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe HSS course with ECE is an effective method for fostering students' systems thinking habits and enhancing their understanding of healthcare systems and patient-centered care. Verifying whether students' interest in various domains and their systems thinking abilities are sustained over time is necessary, and further research is required to design a longitudinal course with continuity.\u003c/p\u003e","manuscriptTitle":"Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 10:25:00","doi":"10.21203/rs.3.rs-4941094/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-23T11:55:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-21T14:22:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-21T14:20:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-08-20T00:28:07+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":"dec5628b-a2b6-4414-9369-9644a9e1615d","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:00:21+00:00","versionOfRecord":{"articleIdentity":"rs-4941094","link":"https://doi.org/10.1186/s12909-025-08250-z","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-12-26 15:57:27","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2024-10-15 10:25:00","video":"","vorDoi":"10.1186/s12909-025-08250-z","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08250-z","workflowStages":[]},"version":"v1","identity":"rs-4941094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4941094","identity":"rs-4941094","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}