The impact of service learning on medical students: A systematic review

The impact of service learning on medical students: A systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of service learning on medical students: A systematic review Joshua Mobberley-Clarke, Jessica Robinson, Katherine Owen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9028837/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Undergraduate medical education has often been characterised by passive learning through observation. Despite medical education reforms including extended assistantships, newly qualified doctors report a lack of preparedness for practice. ‘Service learning’ is a form of education combining learning goals with community benefits. This systematic review explores the impacts of service learning on medical student participants with a view to informing implementation of this approach in supporting preparation for practice. Methods Using predefined search terms, Medline, Embase, Web of Science, PubMed and Education Research Complete databases were searched on 15.10.24 for studies between 2014-2024. Inclusion criteria were medical students, curricular service learning and service-learning involving patient care. All papers were available in English. A reflexive thematic analysis identified common themes in papers, and a CERQUAL table was completed to ascertain confidence in these findings. Results 50 papers were identified for inclusion. The studies covered a range of countries, and sample sizes. The methodology was primarily qualitative, with quantitative studies predominantly using Likert scales or pre/post designs. Six themes identified were confidence, competence, social determinants, team-working, intrinsic motivation and professional identity. Confidence was the most frequently improved domain, particularly in performance of clinical assessment and communication skills. Whilst broadly positive, it was noted there was no change or a negative impact on empathy in 3 papers. Conclusions Service learning enhances medical education by increasing confidence, communication skills, cultural awareness, and teamwork. Student-led clinics have well-documented value in countries without universal healthcare; however a limitation was the low number of papers from outside N America. Many of the impacts were self-reported rather than observed. While some students showed unchanged scores in empathy, service learning generally prepares students for clinical practice and working with underserved populations. Service-learning medical students medical education student-led clinics Figures Figure 1 Background Undergraduate medical education has traditionally been characterised by passive learning through opportunistic observation (1). This style of learning remains prevalent and is further compounded by staffing shortages, high patient volumes and increasing numbers of learners in clinical settings. Newly qualified doctors in the UK report a lack of preparedness for practice: while confident in some respects, they feel particularly underprepared in recognising interprofessional roles, and dealing with uncertainty and prioritisation(2). A 2017 study highlighted preparedness varies significantly depending on the type of medical school curriculum, with notable differences between problem-based learning and traditional curricula(3). The transition to qualified Doctor is widely described as stressful, with themes of lack of support, managing new responsibility, and working in multi-disciplinary teams exacerbating this, however the stress of this transition was mitigated by increased levels of clinical experience whilst an undergraduate (4). “Service learning” has been described as ‘a balance between learning goals and service outcomes’ (5). Originating in the 1960s to address gaps in healthcare for underserved and uninsured communities, student-run clinics are now a fundamental part of American medical school curricula. Present in over 75% of USA medical schools(6), in addition to community benefits, student-led clinics expose students to elements of patient care that may not be seen so often in traditional hospital-based placements, namely enhanced communication, cultural awareness and social determinants of health (7). With the state provision of healthcare present via the National Health Service (NHS) in the UK, there has been less interest in student-led clinics, and concern regarding the ethics of such provision. However, in recent years UK based student-led clinics in physiotherapy and pharmacy have reported benefits to both student and patient (8, 9) (10). With a post-Covid increase in waiting lists, the NHS long-term plan focusing on prevention (11), and an increase in underserved communities through increased migration and austerity, there could now be scope to further enhance the provision of UK student-led clinics. This could aid in bridging the gaps between theory and practice, allowing students a platform to foster patient-centred care attributes early in training and become better prepared for work. Whilst beyond the scope of this paper there is also the potential to support struggling service provision(12). This systematic review will explore what are the impacts for medical students of participating in service learning within medical curricula? The intention is that the findings will inform future implementation of student-led clinics. Methods A systematic review was selected to rigorously synthesise existing research in this area with a view to defining the potential benefits and harms of wider implementation of service learning, with respect to better preparedness for practice of medical graduates. This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Eligibility Criteria The articles were screened for inclusion/exclusion according to the criteria in Table 1 : Table 1 inclusion and exclusion criteria Inclusion Exclusion Published within the last 10 years to reflect most recent evidence Published date prior to 2014 Medical student involvement only due to unique nature of medical student training Other healthcare discipline students – for example student pharmacists, physician associates, nurses, social workers. Service-learning involving patient care to allow applicability to future practice Service-learning opportunities that did not involve patient related care Core curricula or local electives Overseas electives English language papers and non-English language papers which could be reliably translated Non-English language papers which could not be reliably translated Original research in peer-reviewed journals Review articles, conference abstracts and grey literature Studies involving multidisciplinary students were included where data relating to medical students was clearly identifiable. All countries were included to generate a worldwide view of service learning. Information sources On the 15th of October 2024 searches were undertaken on MEDLINE, Embase, Web of Science, PubMed, and Education Research Complete. These databases were selected for their relevance to medical education and healthcare. Citations in the eligible articles included and from other reviews were also screened for potential inclusion Search strategy Databases were searched with the terms provided in Appendix 1, utilising Boolean phrasing, truncation, and exploding terms when appropriate. Data collection process 1358 articles were identified and uploaded into OneNote, with 775 studies identified post de-duplication. These 775 articles were uploaded into the RAYYAN app(13) for screening, and all 3 collaborators screened all articles with RAYYAN into include, exclude, and maybe categories. Any differences in opinion were discussed in a meeting to reach consensus for full-text review. Following this, 104 articles were split between JM and JR for full-text screening. Any queries at this stage were discussed by all three researchers until consensus was reached. Data extraction 50 papers were divided between JM and JR for data extraction with KO performing quality checks. Data was extracted for country, methodology, number of students and key findings, and data was entered into a shared Excel spreadsheet. Study risk of bias and quality assessment Papers were critically analysed for quality and risk of bias using adapted critical appraisal skills programme (CASP) qualitative or cohort study checklists (Appendix 2). Synthesis methods Data was analysed following the reflexive thematic methodology of Braun and Clarke (14). All researchers familiarised themselves with the included studies. Codes were generated manually using excel spreadsheets. Extracted data was reviewed and critically and reflexively discussed by all three researchers, leading to the development of initial themes. Concept mapping was utilised to visually represent these themes and explore the relationships between them, and refutational data was actively sought for each theme. The research team also actively reflected on the robustness of the process, considering their own biases and perspectives during every discussion of data. Certainty assessment To ascertain confidence in these themes, a CERQUAL table with methodological limitations, coherence, adequacy, and relevance was utilised, detailed in Appendix 3. Public and patient participation Medical students are the subjects of this review and were involved in the whole process of the project. Results Study selection 775 studies were identified post- deduplication. Following abstract and full text reviews against inclusion and exclusion criteria 52 studies were included in the final review as outlined in the Prisma diagram (Fig. 1 ). Characteristics of included studies Characteristics of included studies are shown in Appendix 2. 42 studies were from the USA, 3 from the UK and 7 from elsewhere. A wide range of clinical specialties were experienced. Sample sizes ranged from 1-914 medical students. Studies were either qualitative or mixed methods, with data gathered from surveys, focus groups and interviews. Quality appraisals for each study are shown in appendix 2. Findings The six themes that emerged from the review were: confidence, competence, social determinants, team working, intrinsic motivation and professional identity. Subthemes are shown in Table 2 . Table 2 Themes and sub-themes Theme Subthemes Confidence Clinical skills Communication with patients Communication with professionals Competence Clinical knowledge Clinical skills Social determinants of health Cultural competence Awareness of implicit bias Awareness of health inequities Team working Conflict management Confidence Intrinsic motivation Empathy Resilience Professionalism Personal satisfaction Professional identity Confidence Out of the 6 themes to emerge, confidence was the domain with the largest input, with 25 papers contributing to the overall theme(15–38). One of the main sub-themes was improved confidence in clinical skills, particularly undertaking histories and examinations; 16 out of 25 directly mentioned an improvement in this skillset notably Smith (6) describing an increase in confidence in knowledge and skills of a cohort of 914 medical students. One interesting finding is that confidence tends to be increased regardless of speciality a student is placed in. A wide range of specialities are covered in this review varying from Paediatrics (17) to Geriatrics (21), Ophthalmology(16) (39) to Obstetrics and Gynaecology(26, 27). Another strong sub-theme was an overall increase in confidence in the communication sub-domain (15, 25, 31, 40)This confidence related to communication with patients and also professional colleagues (27, 37). There was notably increased confidence in communication in more specialist areas including neonatal intensive care(24), substance misuse (23) and labour ward (37). Competence The next theme to emerge from the review was an increase in clinical competence. There is some heterogeneity in reporting with some direct observation by qualified staff (28, 32) and some self-reported by students themselves (6, 21, 41, 42) An increase in competence around clinical skills was found, with one study in an ophthalmology setting(39), detailing an increased competence in performing specific ophthalmology exams and skills, operating equipment, interpreting examination findings, and translating findings to patients. This theme in clinical skills emerged from multiple other studies with 9 studies (18, 19, 22, 28, 36, 39, 41, 43–45) demonstrating a tangible increase in competence in clinical skills, both in performing the skills and the knowledge that surrounds performing these skills. A study focusing on 35 students in a surgical setting (46) detailed the increase in competence of surgical procedures and care. The largest study in this domain investigated the benefits of service-learning via Clinical Support Worker (CSW) roles prior to graduating(43). This study of 1245 students found 55% of students found the CSW role more beneficial than their medical student role, with 88% agreeing that formal clinical roles are better than placement. 2 papers investigating students in COVID-19 vaccine clinics (18, 19) in total 92 students, detailed improvement in competence of vaccination skills. Although a small study of only 6 students (37), an increase in exam scores was found after undertaking a specific service-learning project in a labour ward. An increase in knowledge is also a sub-domain that has been found in this review. 7 studies (19, 34, 37, 39, 40, 47, 48) mention an increase in knowledge, with clinical areas varying from cardiovascular, vaccinations and obstetrics and gynaecology. Social determinants 16 papers described an increase in knowledge surrounding social determinants of health(24, 29, 33, 37, 38, 41, 42, 46, 48–54) These studies covered a variety of clinical areas and patient groups, including the homeless (49, 51) older patients (21, 54, 55) substance misuse services (47) and marginalised communities(25, 35, 52) The largest study in this domain(56), a study with 1470 students, details how students fostered an appreciation for “cultural competence”, with 20% improvement from the national average in experience of health disparities, and a 25% increase in cultural awareness. This was supported by directors of residency programmes of the surveyed students who described an observed increase in cultural sensitivity. A study of 12 students based in the UK running a homeless outreach programme(49), discussed improved understanding of the needs and barriers of homeless patients and being challenged to address their implicit biases. Team working 8 papers were identified describing an improvement in interprofessional and team working(15, 17, 18, 24, 25, 42, 51, 57) The NICU cuddler curriculum (24) found a 63% increase in competence and comfort working in an interprofessional team. Similarly, a study investigating student-run free clinics and their effect on preparedness for clerkship (58) found an increase in confidence working as part of an interprofessional team and specifically mentions working with translators as this study was part of a Hispanic community. The study with the largest cohort(15) a study with 168 participants, investigated the impacts of interprofessional service learning on students. The study found that students witnessed interprofessional conflicts in clerkship that were like those in service-learning projects and were better equipped to manage these. Intrinsic motivation 18 papers identified the theme of intrinsic motivation and contributed to sub-themes in this domain. 15 of the studies found that sub-themes of resilience, empathy, gratification and value improved because of undertaking service learning. The largest study in this domain(59), including 192 medical students, found that an increased level of ethical conduct and professionalism was realised through undertaking service learning as part of their curriculum. It also found that students increased their level of respect, professionalism and inclusion. A study investigating benefits of volunteering on student wellbeing during COVID-19 (60), included findings for 97 students. The study found that 75% were happier, 77% were emotionally healthier, 88% felt they had more purpose, 57% felt less anxious, 63% felt more empathetic, 67% had increased resilience, 80% felt increased compassion. Although this study presents a positive picture, there were also some smaller percentage increases; 28% felt their physical health was better, 35% felt their sleep was improved and 37% felt an improved ability to deal with loss and disappointment. 3 papers found either a negative impact on empathy or no change to empathy. Although not statistically significant, a study with 188 students(61), found a decrease in empathy post service learning. 2 further studies(25, 55) found that service learning provided no change in empathy or compassion, or that service learning “neither helps nor hinders empathy development”. Professional identity 11 papers contained findings regarding the impact on professional identity. The largest paper in this theme(35) describes an increase in interest working with the underserved and in primary care. 8 of the 11 papers found an increased interest in the specialty of the service learning; these areas tended to be in primary care or working with the underserved, however studies also covered psychiatry, ophthalmology and obstetrics and gynaecology A paper based in obstetrics and gynaecology (62)described student readiness to practice in an OBGYN setting after undertaking the service-learning module. Finally, Mikhail(29) describes how undertaking this specific service-learning module shaped the future careers of student volunteers. Discussion The 6 key domains identified in this review address the various impacts on medical students engaging with service-learning experiences. Although the findings broadly aligned with the expected outcomes, in the intrinsic motivation domain it was found that 3 of 18 studies found service learning to either have a negative impact on empathy or have no impact at all. Service learning is an educational experience which has thus far predominantly been found in countries without a universal healthcare system, explaining why 77% of the literature is from the USA. In these settings there are populations of uninsured patients requiring healthcare where the student run clinics can assist, providing an opportunity for patients to be treated and students to gain. The ethical considerations around this in countries with universal access to healthcare must be considered. Within the reviewed literature there are a handful of studies based in countries with universal healthcare (UK, Netherlands, Canada). These discuss the merits of service learning for underserved populations such as the homeless, indigenous communities and the elderly who may be less likely to access healthcare. Skills gain and applicability to practice By undertaking service-learning opportunities throughout a medical school curriculum such as those in this review, an improvement in clinical confidence and competence could lead to an increased preparedness for incoming FY1 doctors. The major finding of this review was the increase in competence and confidence in performing histories and examinations, communication and other clinical skills, with half of the studies reviewed having findings that align with this key domain. Current research investigating the preparedness of final-year medical students for clinical practice cites unfamiliar surroundings and the reality gap are part of why students feel underprepared (63). Students identified limitations in their knowledge of the roles and responsibilities of a foundation doctor, as well as students not being familiar with existing hospital-specific resources. Social cognitive theory suggests that students learn by observing others and adopting their behaviours (64), however to achieve self-efficacy, the skill learnt requires practice, forming the behavioural arm. In medical school students have limited opportunities to reinforce this observational learning of clinical skills and other practical training. By providing service-learning opportunities, students can reinforce the learning that they have had through the medical school curriculum and foster a sense of self-efficacy in their ability to practice and perform clinical skills. Good teamwork provides benefits for all involved, from the patient to the multidisciplinary team(65). Undertaking service-learning opportunities improves teamwork and interprofessional working, a key element of working as a doctor (42). It also supported clarity of the role of the doctor within the team (63). Application to health inequities Health globally remains subject to significant inequities. Service-learning experiences with underserved groups encourage students to face their own cultural biases which may contribute to the poorer health outcomes for some communities. This authentic learning when combined with reflective practice has the potential to encourage deep challenging of attitudes, way beyond classroom teaching. Shaping students into future clinicians Service learning is a learning environment that can shape individuals into better future clinicians. This can be approached both in terms of the value added by undertaking service learning as previously mentioned, however the area that a student volunteers in can influence careers. A study including 914 students engaging in service-learning project in a primary care setting (35) found that students had an increased interest in working with the underserved and working in primary care because of volunteering in this type of setting. Lynn and Byrne (66) found that being placed on a ward in service-learning type settings allowed students to feel more prepared to practice, an invaluable use of students' time. Not only is the role able to prepare students in terms of their clinical skills and practical abilities, but by being exposed to working at the coalface students gain experience of their future working environment before they assume formal responsibility. Preparedness fosters a level of confidence in subjects, as often preparedness involves acquiring more knowledge and experience, promoting domain-specific self-efficacy, agency and control (67). If through service-learning students can gain a safe level of self-efficacy, it will shape them into prepared and safe Strengths and limitations of this study Broad inclusion criteria ensured evidence from a wide range of settings for service learning Majority of included papers from USA context may impact applicability Reports of service learning in grey literature were excluded for robustness but may contain further useful evidence Conclusion Service learning can provide an opportunity for students to enhance their medical education. The review has found that through service-learning students become more competent, confident, culturally aware, intrinsically motivated to practice medicine and more able understand their place in a medical team. These are components to shape able and prepared future clinicians, which ultimately can be enabled through service learning. More research is needed to investigate how service learning can be applied to countries with a universal healthcare system ethically, however, some limited research is available on how this can be implemented. Declarations The review was not registered as it began as a student project. Declarations Ethics approval Not applicable. Supporting evidence Supporting evidence can be found in the appendices. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Author contributions All authors were fully involved in all stages of the project and contributed equally. References 1. Spencer J. Learning and teaching in the clinical environment. BMJ. 2003;326(1756–1833 (Electronic)):591. 2. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13(1):117. 3. Miles S, Kellett J, Leinster SJ. Medical graduates' preparedness to practice: a comparison of undergraduate medical school training. BMC Medical Education. 2017;17(1472–6920 (Electronic)). 4. Brennan N, Corrigan O Fau - Allard J, Allard J Fau - Archer J, Archer J Fau - Barnes R, Barnes R Fau - Bleakley A, Bleakley A Fau - Collett T, et al. The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors. Med Educ. 2010;44(1365–2923 (Electronic)):449 − 58. 5. Furco A. Service-learning: A balanced approach to experiential education. Revista Educación Global. 2011:64–70. 6. Smith S, Thomas R, 3rd, Cruz M, Griggs R, Moscato B, Ferrara A. Presence and characteristics of student-run free clinics in medical schools. JAMA. 2014;10(1538–3598 (Electronic)):2407-10. 7. Briggs L, and Fronek P. Student Experiences and Perceptions of Participation in Student-Led Health Clinics: A Systematic Review. Journal of Social Work Education. 2020;56(2):238 − 59. 8. Wynne D, Cooper K. Students' perceptions of a UK physiotherapy student-led clinic. Clin Teach. 2023;20(1743-498X (Electronic)). 9. Chin S, Richardson CA-O, Gardner A, Nazar HA-O. The impact and user experience of a student-led clinic providing preventative services. Int J Pharm Pract. 2024;32(2042–7174 (Electronic)):237 − 43. 10. Moseley J, Hellawell M, Graham C, Briggs A. Evaluation of a large group supervision model in a university student-led physiotherapy clinic. British Journal of Healthcare Management. 2022;28:61 − 7. 11. NHSEngland. The NHS Long-term Plan. 2019. 12. Stokel-Walker C. What can be done to ease today’s pressures in the NHS? BMJ. 2023;380:p88. 13. Ouzzani M, Hammady,H., Fedorowicz,Z., Elmagarmid, A.. Rayyan — a web and mobile app for systematic reviews. Systematic Reviews. 2016;5. 14. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77–101. 15. Bouzaher MH, Trinkle DB, Mutcheson RB. Interprofessional Service Learning in Medical Education: a Year-Over-Year Assessment of Student Feedback. Med Sci Ed. 2020;30(2156–8650 (Electronic)):775 − 81. 16. Burton E, Assi L, Vongsachang H, Swenor BK, Srikumaran D, Woreta FA, et al. Demographics, clinical interests, and ophthalmology skills confidence of medical student volunteers and non-volunteers in an extracurricular community vision screening service-learning program. BMC Medical Education. 2022;22(1):143. 17. Cappetto KD, Ehrlich B, Anderson EA, Huynh AT, Tran J, Hudon K. The benefits of undergraduate medical students delivering free preparticipation physical evaluations in collaboration with a K-12 school district. BMC Medical Education. 2024;24(1):901. 18. Carroll PH, J.. Development and evaluation of an interprofessional student-led influenza vaccination clinic for medical, nursing and pharmacy students. Pharm Pract. 2021;19(1885-642X (Print)):2449. 19. Chen G, Kazmi M, Chen D, Phillips J. Improving Medical Student Clinical Knowledge and Skills Through Influenza Education. Med Sci Educ. 2021;31(2156–8650 (Electronic)):1645-51. 20. Domaradzki J. 'Who Else If Not We'. Medical Students' Perception and Experiences with Volunteering during the COVID-19 Crisis in Poznan, Poland.. Int J Environ Res Public Health. 2022;19(1660–4601 (Electronic)):2314. 21. Fukuma N, Reilly JM. Geriatrics Education: Phone Calls With Older Adults and Medical Students. Fam Med. 2023;25(1938–3800 (Electronic)):471-5. 22. Griswold AA-O, Klein JA-OX, Dusaj NA-OX, Zhu J, Keeler A, Abramson EL, et al. Students as Community Vaccinators: Implementation of A Service-Learning COVID-19 Vaccination Program. LID − 10.3390/vaccines10071058 [doi] LID − 1058. Vaccines (Basel). 2022;10(2076-393X (Print)):1058. 23. Gummadi NA-OX, D'Amico M, Chandra P, Krumholz JO, Mumber HE, Hoyo L, et al. Impact of cuddler service-learning program in medical student education of opioid use disorder in pregnancy and neonatal opioid withdrawal syndrome. Substance Abuse. 2021;42(1547 − 0164 (Electronic)):951-6. 24. Insley E, Tedesco K, Litman EA-O, Mangalapally N, Gicewicz C, Monaco-Brown ML. The NICU Cuddler Curriculum: A Service-Learning Curriculum for Preclinical Medical Students in the Neonatal Intensive Care Unit. MedEdPORTAL. 2021;17(2374–8265 (Electronic)):11069. 25. Kodweis KR, Allen RB, Deschamp EI, Bihl AT, LeVine DAM, Hall EA. Impact of student-run clinic participation on empathy and interprofessional skills development in medical and pharmacy students. Explor Res Clin Soc Pharm. 2023;11(2667–2766 (Electronic)):100306. 26. Lilliecreutz C, Holm ACS, Dahlgren MA, Blomberg M. Student-led clinic cervical cancer screening—medical students’ views on progression of learning, quality of Pap smears and women´s experiences of the visit – a mixed methods study. BMC Medical Education. 2023;23(1):218. 27. Lu WH, Pang L, Strano-Paul L. The Impact of COVID-19 Service Learning on Medical Student Professional Identity Formation. J Med Educ Curric Dev. 2024;11(2382 − 1205 (Print)). 28. McQuillan T, Wilcox-Fogel N, Kraus E, Ladd A, Fredericson M. Integrating Musculoskeletal Education and Patient Care at Medical Student-Run Free Clinics. PM R. 2017;9(1934 − 1563 (Electronic)):1117-21. 29. Mikhail H, Button B, LeBlanc J, Cervin C, Cameron E. Operation Remote Immunity: exploring the impact of a service-learning elective in remote Indigenous communities. BMC Medical Education. 2023;23(1):456. 30. Milford E, Morrison K, Teutsch C, Nelson BB, Herman A, King M, et al. Out of the classroom and into the community: medical students consolidate learning about health literacy through collaboration with Head Start. BMC Medical Education. 2016;16(1472–6920 (Electronic)). 31. Nghiem J, Liu M, Fruitman K, Zhou C, Zonana J, Outram T, et al. Exploring Preclinical Medical Students' Experience Facilitating Group Dialectical Behavior Therapy (DBT) for a Student-Run Mental Health Clinic: A Qualitative Study. Acad Psychiatry. 2024;48(1545–7230 (Electronic)):334-8. 32. Schutte T, Tichelaar J, Dekker RS, Thijs A, de Vries TPGM, Kusurkar RA, et al. Motivation and competence of participants in a learner-centered student-run clinic: an exploratory pilot study. BMC Medical Education. 2017;17(1):23. 33. Server S, Uddin S, GoodSmith M, Zhang A, Sherer R, Lio J. Learning at a social distance: A medical student telehealth service for COVID-19 patients. MedEdPublish. 2016(2312–7996 (Electronic)). 34. Shakartzi H, Wenren L, Fernandes S, Marino R, Meade M, Pierre-Joseph N, et al. DREAM: Empowering Preclinical Medical Students With Labor Support. MedEdPORTAL. 2018;14(2374–8265 (Electronic)). 35. Smith SD, Yoon R, Johnson ML, Natarajan L, Beck E, Beck E. The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care. J Health Care. 2014;25(1548–6869 (Electronic)):877 − 89. 36. Ueberroth BE, Siegel DR. The Utility of EMRs in Student Run Clinics. The Clinical Teacher. 2020;17(2):159 − 62. 37. Weber LC, Ortega JC, Bastea S, Robitz RA, Mumma BE. Women Leading Healthy Change: A Reciprocal Learning Experience for Women in the Sex Trade and Medical Students. MedEdPORTAL. 2021;17(2374–8265 (Electronic)):11154. 38. Wong CK, Berens PM, Katta MV, Lie M, Fall D, Shah A, et al. From education to action: Development and evaluation of a student-directed service learning program. Med Teach. 2021;44(1466-187X (Electronic)):541-5. 39. Burton E, Assi L, Vongsachang H, Swenor BK, Srikumaran D, Woreta FA, et al. Demographics, clinical interests, and ophthalmology skills confidence of medical student volunteers and non-volunteers in an extracurricular community vision screening service-learning program. (1472–6920 (Electronic)). 40. Carroll PA-O, Hanrahan JA-O. Development and evaluation of an interprofessional student-led influenza vaccination clinic for medical, nursing and pharmacy students. (1885-642X (Print)). 41. Adel FW, Berggren RE, Esterl RM, Ratelle JT. Student-run free clinic volunteers: who they are and what we can learn from them. BMC Medical Education. 2021;21(1):356. 42. Ryan M, Vanderbilt AA, Mayer SD, Gregory A. Interprofessional education as a method to address health needs in a Hispanic community setting: A pilot study. J Interprof Care. 2015;29(1469–9567 (Electronic)):515-7. 43. Byrne MA-OX, Alexander L, Wan JCM, Brown MA-O, Arora AA-O, Harvey A, et al. Clinical support during COVID-19: An opportunity for service and learning? A cross-sectional survey of UK medical students. Med Teach. 2023;45(1466-187X (Electronic)):859 − 70. 44. Cohen A, Hu S, Bellon M, Wang NE, Sebok-Syer S. A lasting impact? Exploring the immediate and longitudinal impact of an emergency department service learning help desk program. AEM Educ Train. 2022;6(2472–5390 (Electronic)):e10760. 45. Smith Sd Fau - Yoon R, Yoon R Fau - Johnson ML, Johnson Ml Fau - Natarajan L, Natarajan L Fau - Beck E, Beck E. The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care. (1548–6869 (Electronic)). 46. Janeway MG, Lee SY, Caron E, Sausjord IK, Allee L, Sanchez SE, et al. Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening. Am J Surg. 2020;219(1879–1883 (Electronic)):346 − 54. 47. Mishan L, Dragatsi D. Student-Run Clinics: A Novel Approach to Integrated Care, Teaching and Recruitment. Community Mental Health Journal. 2017;53. 48. Shah NS, Rassiwala J, Ducharme-Smith AL, Klein DA, Kim AS, Leung C, et al. Development and evaluation of a service-learning model for preclinical student education in cardiovascular disease prevention. Adv Med Educ Pract. 2016;7(1179–7258 (Print)). 49. Alzeera MA-O, Ward AA-O. Involving medical students in the planning and delivery of a vaccination and health screening outreach clinic. (1475-990X (Electronic)). 50. Greer PJ, Jr., Brown Dr Fau - Brewster LG, Brewster Lg Fau - Lage OG, Lage Og Fau - Esposito KF, Esposito Kf Fau - Whisenant EB, Whisenant Eb Fau - Anderson FW, et al. Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine. (1938-808X (Electronic)). 51. Chrisman-Khawam L, Abdullah N, Dhoopar A. Teaching health-care trainees empathy and homelessness IQ through service learning, reflective practice, and altruistic attribution. Int J Psychiatry Med. 2017;52(1541–3527 (Electronic)):245 − 54. 52. Rockey NG, Weiskittel TM, Linder KE, Ridgeway Jl, Wieland Ml. A mixed methods study to evaluate the impact of a student-run clinic on undergraduate medical education. BMC Medical Education. 2021;21(1472–6920 (Electronic)). 53. Gimpel N, Kindratt T, Dawson A, Pagels P. Community action research track: Community-based participatory research and service-learning experiences for medical students. Perspect Med Educ. 2018;7(2212–2761 (Print)):139 − 43. 54. Ng KYY, Leung GYC, Tey AJ, Chaung JQ, Lee SM, Soundararajan A, et al. Bridging the intergenerational gap: the outcomes of a student-initiated, longitudinal, inter-professional, inter-generational home visit program. (1472–6920 (Electronic)). 55. Laks J, Wilson LA, Khandelwal C, Footman E, Jamison M, Roberts E. Service-Learning in Communities of Elders (SLICE): Development and Evaluation of an Introductory Geriatrics Course for Medical Students. Teach Learn Med. 2014;28(1532–8015 (Electronic)):210-8. 56. Greer Jr PJ, Brown DR, Brewster LG, Lage OG, Esposito KF, Whisenant EB, et al. Socially accountable medical education: an innovative approach at Florida International University Herbert Wertheim College of Medicine. Academic Medicine. 2018;93(1):60 − 5. 57. Schutte T, Tichelaar J, Donker E, Richir MC, Westerman M, van Agtmael MA. Clarifying learning experiences in student-run clinics: a qualitative study. BMC Medical Education. 2018;18(1472–6920 (Electronic)). 58. Kalistratova VA-O, Nisanova AA-O, Shi LA-O. Student-run free clinics may enhance medical students' self-confidence in their clinical skills and preparedness for clerkships. Med Educ Online. 2024;29(1087–2981 (Electronic)):2348276. 59. Bamdas JAM, Averkiou P, Jacomino M. Service-Learning Programs and Projects for Medical Students Engaged With the Community. Cureus. 2022;14(2168–8184 (Print)). 60. Phillips HE, Jennings RB, Outhwaite IR, Grosser S, Chandra M, Ende V, et al. Motivation to Impact: Medical Student Volunteerism in the COVID 19 Pandemic. Med Sci Ed. 2022;32(2156–8650 (Electronic)):1149-57. 61. Modi A, Fascelli M, Daitch Z, Hojat M. Evaluating the Relationship Between Participation in Student-Run Free Clinics and Changes in Empathy in Medical Students. J Prim Care Community Health. 2017;8(2150 − 1327 (Electronic)):122-6. 62. Fein AW, Paladine HL. Impact of a Student-Run Free Clinic's Women's Health Program on Perceived Readiness for Clinical Rotations. PRIMER. 2020;14(2575–7873 (Electronic)). 63. Hawkins N, Younan H-C, Fyfe M, Parekh R, McKeown A. Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on-call simulation. BMC Medical Education. 2021;21(1):165. 64. Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ, US: Prentice-Hall, Inc; 1986. xiii, 617-xiii, p. 65. Babiker A, El Husseini M, Al Nemri A, Al Frayh A, Al Juryyan N, Faki MO, et al. Health care professional development: Working as a team to improve patient care. Sudan J Paediatr. 2014;14(0256–4408 (Print)):9 − 6. 66. Lynn E, Byrne M. Balance Service and Learning: Insights From Volunteer Experiences of U.K. Medical Students During the COVID-19 Pandemic. Academic medicine : journal of the Association of American Medical Colleges. 2023;99. 67. Carroll P, Sweeny K, Shepperd JA. Forsaking optimism. Review of General Psychology. 2006;10(1):56–73. Additional Declarations No competing interests reported. Supplementary Files Appendix1Searches.docx Appendix2includedpapersandCASPappraisal.docx Appendix3cerqualappraisal.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Apr, 2026 Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers invited by journal 08 Apr, 2026 Editor invited by journal 13 Mar, 2026 Editor assigned by journal 12 Mar, 2026 Submission checks completed at journal 12 Mar, 2026 First submitted to journal 04 Mar, 2026 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. 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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-9028837","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":622071007,"identity":"823b7479-1506-474f-a488-800042d84e5d","order_by":0,"name":"Joshua Mobberley-Clarke","email":"","orcid":"","institution":"University of Warwick","correspondingAuthor":false,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Mobberley-Clarke","suffix":""},{"id":622071008,"identity":"1bbab324-fa56-4b9e-b2e9-61ce63f9ddd1","order_by":1,"name":"Jessica Robinson","email":"","orcid":"","institution":"University of Warwick","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Robinson","suffix":""},{"id":622071014,"identity":"81c111df-0efd-4d83-b169-5bc9b07666c3","order_by":2,"name":"Katherine Owen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABGklEQVRIiWNgGAWjYBACCQYGNggFATZg8gAQggAzdi3MKFrSiNYCB4ehNB4tku3njz34uMcij5+B+ZjExx3nE/tnnzE88OMMgzx/A4+xARYt0jzJ7IYznkkUSzawpUnOPHM7cca5HIODPTcYDGcc4DFOwKJFjiGZTZrngETihgM8Zrd5227nNpzh3XCY4QMD4wYGHuMD2LTwP2aT/gPUsh+k5W/budz5UC32uLRISwBtYQDZwgDUwth2IHcDWMsNBpAIVodJznhsJtkD1DLjMFv6z9625PqNZ/g/HOw5I5EMFCnG5n2J84nPJH4cqEvsb28+bPCzzc5Y7gxb8ocfx2xsgSKbJbBoQQC0OJDAESujYBSMglEwCogBAH8pZpHN3Jl9AAAAAElFTkSuQmCC","orcid":"","institution":"University of Warwick","correspondingAuthor":true,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Owen","suffix":""}],"badges":[],"createdAt":"2026-03-04 10:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9028837/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9028837/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107482237,"identity":"63ee8fc1-1e80-4874-844f-2a05c076d5a9","added_by":"auto","created_at":"2026-04-22 02:22:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92198,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9028837/v1/3bc0c96a53fb8e4d9179c2c9.png"},{"id":107484791,"identity":"cb7c0e2e-b9c1-4f27-9d2a-a0eb4cb7f21a","added_by":"auto","created_at":"2026-04-22 02:33:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":348178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9028837/v1/63dcba12-a043-4eb5-9fba-98a0745be796.pdf"},{"id":107242902,"identity":"15f4cd36-29a0-4f8b-a346-647dc70a3528","added_by":"auto","created_at":"2026-04-19 07:46:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1236595,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1Searches.docx","url":"https://assets-eu.researchsquare.com/files/rs-9028837/v1/d3a748edc2f9a0b027633acf.docx"},{"id":107242904,"identity":"c217fe46-845f-41d4-9b54-b6306d6d6f4e","added_by":"auto","created_at":"2026-04-19 07:46:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":36653,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2includedpapersandCASPappraisal.docx","url":"https://assets-eu.researchsquare.com/files/rs-9028837/v1/bf4c89831e7064030f88868b.docx"},{"id":107242906,"identity":"dbac0457-a1ef-447a-bd4c-457473c9d1c5","added_by":"auto","created_at":"2026-04-19 07:46:15","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18935,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3cerqualappraisal.docx","url":"https://assets-eu.researchsquare.com/files/rs-9028837/v1/f0dfa8d6219698ac3d7ea2bc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of service learning on medical students: A systematic review","fulltext":[{"header":"Background","content":"\u003cp\u003eUndergraduate medical education has traditionally been characterised by passive learning through opportunistic observation (1). This style of learning remains prevalent and is further compounded by staffing shortages, high patient volumes and increasing numbers of learners in clinical settings. Newly qualified doctors in the UK report a lack of preparedness for practice: while confident in some respects, they feel particularly underprepared in recognising interprofessional roles, and dealing with uncertainty and prioritisation(2). A 2017 study highlighted preparedness varies significantly depending on the type of medical school curriculum, with notable differences between problem-based learning and traditional curricula(3). The transition to qualified Doctor is widely described as stressful, with themes of lack of support, managing new responsibility, and working in multi-disciplinary teams exacerbating this, however the stress of this transition was mitigated by increased levels of clinical experience whilst an undergraduate (4).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Service learning\u0026rdquo; has been described as \u0026lsquo;a balance between learning goals and service outcomes\u0026rsquo; (5). Originating in the 1960s to address gaps in healthcare for underserved and uninsured communities, student-run clinics are now a fundamental part of American medical school curricula. Present in over 75% of USA medical schools(6), in addition to community benefits, student-led clinics expose students to elements of patient care that may not be seen so often in traditional hospital-based placements, namely enhanced communication, cultural awareness and social determinants of health (7).\u003c/p\u003e \u003cp\u003eWith the state provision of healthcare present via the National Health Service (NHS) in the UK, there has been less interest in student-led clinics, and concern regarding the ethics of such provision. However, in recent years UK based student-led clinics in physiotherapy and pharmacy have reported benefits to both student and patient (8, 9) (10). With a post-Covid increase in waiting lists, the NHS long-term plan focusing on prevention (11), and an increase in underserved communities through increased migration and austerity, there could now be scope to further enhance the provision of UK student-led clinics. This could aid in bridging the gaps between theory and practice, allowing students a platform to foster patient-centred care attributes early in training and become better prepared for work. Whilst beyond the scope of this paper there is also the potential to support struggling service provision(12).\u003c/p\u003e \u003cp\u003eThis systematic review will explore what are the impacts for medical students of participating in service learning within medical curricula? The intention is that the findings will inform future implementation of student-led clinics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA systematic review was selected to rigorously synthesise existing research in this area with a view to defining the potential benefits and harms of wider implementation of service learning, with respect to better preparedness for practice of medical graduates. This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility Criteria\u003c/h2\u003e \u003cp\u003eThe articles were screened for inclusion/exclusion according to the criteria in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003einclusion and exclusion criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublished within the last 10 years to reflect most recent evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublished date prior to 2014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical student involvement only due to unique nature of medical student training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther healthcare discipline students \u0026ndash; for example student pharmacists, physician associates, nurses, social workers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService-learning involving patient care to allow applicability to future practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService-learning opportunities that did not involve patient related care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCore curricula or local electives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverseas electives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish language papers and non-English language papers which could be reliably translated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-English language papers which could not be reliably translated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOriginal research in peer-reviewed journals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview articles, conference abstracts and grey literature\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStudies involving multidisciplinary students were included where data relating to medical students was clearly identifiable. All countries were included to generate a worldwide view of service learning.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cp\u003eOn the 15th of October 2024 searches were undertaken on MEDLINE, Embase, Web of Science, PubMed, and Education Research Complete. These databases were selected for their relevance to medical education and healthcare. Citations in the eligible articles included and from other reviews were also screened for potential inclusion\u003c/p\u003e\n\u003ch3\u003eSearch strategy\u003c/h3\u003e\n\u003cp\u003eDatabases were searched with the terms provided in Appendix 1, utilising Boolean phrasing, truncation, and exploding terms when appropriate.\u003c/p\u003e\n\u003ch3\u003eData collection process\u003c/h3\u003e\n\u003cp\u003e1358 articles were identified and uploaded into OneNote, with 775 studies identified post de-duplication. These 775 articles were uploaded into the RAYYAN app(13) for screening, and all 3 collaborators screened all articles with RAYYAN into include, exclude, and maybe categories. Any differences in opinion were discussed in a meeting to reach consensus for full-text review. Following this, 104 articles were split between JM and JR for full-text screening. Any queries at this stage were discussed by all three researchers until consensus was reached.\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003e50 papers were divided between JM and JR for data extraction with KO performing quality checks. Data was extracted for country, methodology, number of students and key findings, and data was entered into a shared Excel spreadsheet.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy risk of bias and quality assessment\u003c/h2\u003e \u003cp\u003ePapers were critically analysed for quality and risk of bias using adapted critical appraisal skills programme (CASP) qualitative or cohort study checklists (Appendix 2).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSynthesis methods\u003c/h3\u003e\n\u003cp\u003eData was analysed following the reflexive thematic methodology of Braun and Clarke (14). All researchers familiarised themselves with the included studies. Codes were generated manually using excel spreadsheets. Extracted data was reviewed and critically and reflexively discussed by all three researchers, leading to the development of initial themes. Concept mapping was utilised to visually represent these themes and explore the relationships between them, and refutational data was actively sought for each theme. The research team also actively reflected on the robustness of the process, considering their own biases and perspectives during every discussion of data.\u003c/p\u003e\n\u003ch3\u003eCertainty assessment\u003c/h3\u003e\n\u003cp\u003eTo ascertain confidence in these themes, a CERQUAL table with methodological limitations, coherence, adequacy, and relevance was utilised, detailed in Appendix 3.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePublic and patient participation\u003c/h2\u003e \u003cp\u003eMedical students are the subjects of this review and were involved in the whole process of the project.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003e775 studies were identified post- deduplication. Following abstract and full text reviews against inclusion and exclusion criteria 52 studies were included in the final review as outlined in the Prisma diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of included studies\u003c/h2\u003e \u003cp\u003eCharacteristics of included studies are shown in Appendix 2. 42 studies were from the USA, 3 from the UK and 7 from elsewhere. A wide range of clinical specialties were experienced. Sample sizes ranged from 1-914 medical students. Studies were either qualitative or mixed methods, with data gathered from surveys, focus groups and interviews. Quality appraisals for each study are shown in appendix 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFindings\u003c/h2\u003e \u003cp\u003eThe six themes that emerged from the review were: confidence, competence, social determinants, team working, intrinsic motivation and professional identity. Subthemes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical skills\u003c/p\u003e \u003cp\u003eCommunication with patients\u003c/p\u003e \u003cp\u003eCommunication with professionals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical knowledge\u003c/p\u003e \u003cp\u003eClinical skills\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial determinants of health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCultural competence\u003c/p\u003e \u003cp\u003eAwareness of implicit bias\u003c/p\u003e \u003cp\u003eAwareness of health inequities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeam working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConflict management\u003c/p\u003e \u003cp\u003eConfidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrinsic motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003cp\u003eResilience\u003c/p\u003e \u003cp\u003eProfessionalism\u003c/p\u003e \u003cp\u003ePersonal satisfaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eConfidence\u003c/h2\u003e \u003cp\u003eOut of the 6 themes to emerge, confidence was the domain with the largest input, with 25 papers contributing to the overall theme(15\u0026ndash;38). One of the main sub-themes was improved confidence in clinical skills, particularly undertaking histories and examinations; 16 out of 25 directly mentioned an improvement in this skillset notably Smith (6) describing an increase in confidence in knowledge and skills of a cohort of 914 medical students. One interesting finding is that confidence tends to be increased regardless of speciality a student is placed in. A wide range of specialities are covered in this review varying from Paediatrics (17) to Geriatrics (21), Ophthalmology(16) (39) to Obstetrics and Gynaecology(26, 27).\u003c/p\u003e \u003cp\u003eAnother strong sub-theme was an overall increase in confidence in the communication sub-domain (15, 25, 31, 40)This confidence related to communication with patients and also professional colleagues (27, 37). There was notably increased confidence in communication in more specialist areas including neonatal intensive care(24), substance misuse (23) and labour ward (37).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCompetence\u003c/h2\u003e \u003cp\u003eThe next theme to emerge from the review was an increase in clinical competence. There is some heterogeneity in reporting with some direct observation by qualified staff (28, 32) and some self-reported by students themselves (6, 21, 41, 42)\u003c/p\u003e \u003cp\u003eAn increase in competence around clinical skills was found, with one study in an ophthalmology setting(39), detailing an increased competence in performing specific ophthalmology exams and skills, operating equipment, interpreting examination findings, and translating findings to patients. This theme in clinical skills emerged from multiple other studies with 9 studies (18, 19, 22, 28, 36, 39, 41, 43\u0026ndash;45) demonstrating a tangible increase in competence in clinical skills, both in performing the skills and the knowledge that surrounds performing these skills. A study focusing on 35 students in a surgical setting (46) detailed the increase in competence of surgical procedures and care. The largest study in this domain investigated the benefits of service-learning via Clinical Support Worker (CSW) roles prior to graduating(43). This study of 1245 students found 55% of students found the CSW role more beneficial than their medical student role, with 88% agreeing that formal clinical roles are better than placement. 2 papers investigating students in COVID-19 vaccine clinics (18, 19) in total 92 students, detailed improvement in competence of vaccination skills.\u003c/p\u003e \u003cp\u003eAlthough a small study of only 6 students (37), an increase in exam scores was found after undertaking a specific service-learning project in a labour ward.\u003c/p\u003e \u003cp\u003eAn increase in knowledge is also a sub-domain that has been found in this review. 7 studies (19, 34, 37, 39, 40, 47, 48) mention an increase in knowledge, with clinical areas varying from cardiovascular, vaccinations and obstetrics and gynaecology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSocial determinants\u003c/h2\u003e \u003cp\u003e16 papers described an increase in knowledge surrounding social determinants of health(24, 29, 33, 37, 38, 41, 42, 46, 48\u0026ndash;54) These studies covered a variety of clinical areas and patient groups, including the homeless (49, 51) older patients (21, 54, 55) substance misuse services (47) and marginalised communities(25, 35, 52)\u003c/p\u003e \u003cp\u003eThe largest study in this domain(56), a study with 1470 students, details how students fostered an appreciation for \u0026ldquo;cultural competence\u0026rdquo;, with 20% improvement from the national average in experience of health disparities, and a 25% increase in cultural awareness. This was supported by directors of residency programmes of the surveyed students who described an observed increase in cultural sensitivity. A study of 12 students based in the UK running a homeless outreach programme(49), discussed improved understanding of the needs and barriers of homeless patients and being challenged to address their implicit biases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTeam working\u003c/h2\u003e \u003cp\u003e8 papers were identified describing an improvement in interprofessional and team working(15, 17, 18, 24, 25, 42, 51, 57)\u003c/p\u003e \u003cp\u003eThe NICU cuddler curriculum (24) found a 63% increase in competence and comfort working in an interprofessional team. Similarly, a study investigating student-run free clinics and their effect on preparedness for clerkship (58) found an increase in confidence working as part of an interprofessional team and specifically mentions working with translators as this study was part of a Hispanic community.\u003c/p\u003e \u003cp\u003eThe study with the largest cohort(15) a study with 168 participants, investigated the impacts of interprofessional service learning on students. The study found that students witnessed interprofessional conflicts in clerkship that were like those in service-learning projects and were better equipped to manage these.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eIntrinsic motivation\u003c/h2\u003e \u003cp\u003e18 papers identified the theme of intrinsic motivation and contributed to sub-themes in this domain. 15 of the studies found that sub-themes of resilience, empathy, gratification and value improved because of undertaking service learning.\u003c/p\u003e \u003cp\u003eThe largest study in this domain(59), including 192 medical students, found that an increased level of ethical conduct and professionalism was realised through undertaking service learning as part of their curriculum. It also found that students increased their level of respect, professionalism and inclusion.\u003c/p\u003e \u003cp\u003eA study investigating benefits of volunteering on student wellbeing during COVID-19 (60), included findings for 97 students. The study found that 75% were happier, 77% were emotionally healthier, 88% felt they had more purpose, 57% felt less anxious, 63% felt more empathetic, 67% had increased resilience, 80% felt increased compassion. Although this study presents a positive picture, there were also some smaller percentage increases; 28% felt their physical health was better, 35% felt their sleep was improved and 37% felt an improved ability to deal with loss and disappointment.\u003c/p\u003e \u003cp\u003e3 papers found either a negative impact on empathy or no change to empathy. Although not statistically significant, a study with 188 students(61), found a decrease in empathy post service learning. 2 further studies(25, 55) found that service learning provided no change in empathy or compassion, or that service learning \u0026ldquo;neither helps nor hinders empathy development\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eProfessional identity\u003c/h2\u003e \u003cp\u003e11 papers contained findings regarding the impact on professional identity.\u003c/p\u003e \u003cp\u003eThe largest paper in this theme(35) describes an increase in interest working with the underserved and in primary care. 8 of the 11 papers found an increased interest in the specialty of the service learning; these areas tended to be in primary care or working with the underserved, however studies also covered psychiatry, ophthalmology and obstetrics and gynaecology\u003c/p\u003e \u003cp\u003eA paper based in obstetrics and gynaecology (62)described student readiness to practice in an OBGYN setting after undertaking the service-learning module.\u003c/p\u003e \u003cp\u003eFinally, Mikhail(29) describes how undertaking this specific service-learning module shaped the future careers of student volunteers.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 6 key domains identified in this review address the various impacts on medical students engaging with service-learning experiences. Although the findings broadly aligned with the expected outcomes, in the intrinsic motivation domain it was found that 3 of 18 studies found service learning to either have a negative impact on empathy or have no impact at all.\u003c/p\u003e \u003cp\u003eService learning is an educational experience which has thus far predominantly been found in countries without a universal healthcare system, explaining why 77% of the literature is from the USA. In these settings there are populations of uninsured patients requiring healthcare where the student run clinics can assist, providing an opportunity for patients to be treated and students to gain. The ethical considerations around this in countries with universal access to healthcare must be considered. Within the reviewed literature there are a handful of studies based in countries with universal healthcare (UK, Netherlands, Canada). These discuss the merits of service learning for underserved populations such as the homeless, indigenous communities and the elderly who may be less likely to access healthcare.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eSkills gain and applicability to practice\u003c/h2\u003e \u003cp\u003eBy undertaking service-learning opportunities throughout a medical school curriculum such as those in this review, an improvement in clinical confidence and competence could lead to an increased preparedness for incoming FY1 doctors.\u003c/p\u003e \u003cp\u003eThe major finding of this review was the increase in competence and confidence in performing histories and examinations, communication and other clinical skills, with half of the studies reviewed having findings that align with this key domain. Current research investigating the preparedness of final-year medical students for clinical practice cites unfamiliar surroundings and the reality gap are part of why students feel underprepared (63). Students identified limitations in their knowledge of the roles and responsibilities of a foundation doctor, as well as students not being familiar with existing hospital-specific resources.\u003c/p\u003e \u003cp\u003eSocial cognitive theory suggests that students learn by observing others and adopting their behaviours (64), however to achieve self-efficacy, the skill learnt requires practice, forming the behavioural arm. In medical school students have limited opportunities to reinforce this observational learning of clinical skills and other practical training. By providing service-learning opportunities, students can reinforce the learning that they have had through the medical school curriculum and foster a sense of self-efficacy in their ability to practice and perform clinical skills.\u003c/p\u003e \u003cp\u003eGood teamwork provides benefits for all involved, from the patient to the multidisciplinary team(65). Undertaking service-learning opportunities improves teamwork and interprofessional working, a key element of working as a doctor (42). It also supported clarity of the role of the doctor within the team (63).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eApplication to health inequities\u003c/h2\u003e \u003cp\u003eHealth globally remains subject to significant inequities. Service-learning experiences with underserved groups encourage students to face their own cultural biases which may contribute to the poorer health outcomes for some communities. This authentic learning when combined with reflective practice has the potential to encourage deep challenging of attitudes, way beyond classroom teaching.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eShaping students into future clinicians\u003c/h2\u003e \u003cp\u003eService learning is a learning environment that can shape individuals into better future clinicians. This can be approached both in terms of the value added by undertaking service learning as previously mentioned, however the area that a student volunteers in can influence careers. A study including 914 students engaging in service-learning project in a primary care setting (35) found that students had an increased interest in working with the underserved and working in primary care because of volunteering in this type of setting.\u003c/p\u003e \u003cp\u003eLynn and Byrne (66) found that being placed on a ward in service-learning type settings allowed students to feel more prepared to practice, an invaluable use of students' time. Not only is the role able to prepare students in terms of their clinical skills and practical abilities, but by being exposed to working at the coalface students gain experience of their future working environment before they assume formal responsibility.\u003c/p\u003e \u003cp\u003ePreparedness fosters a level of confidence in subjects, as often preparedness involves acquiring more knowledge and experience, promoting domain-specific self-efficacy, agency and control (67).\u003c/p\u003e \u003cp\u003eIf through service-learning students can gain a safe level of self-efficacy, it will shape them into prepared and safe\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations of this study\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eBroad inclusion criteria ensured evidence from a wide range of settings for service learning\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMajority of included papers from USA context may impact applicability\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReports of service learning in grey literature were excluded for robustness but may contain further useful evidence\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eService learning can provide an opportunity for students to enhance their medical education. The review has found that through service-learning students become more competent, confident, culturally aware, intrinsically motivated to practice medicine and more able understand their place in a medical team. These are components to shape able and prepared future clinicians, which ultimately can be enabled through service learning. More research is needed to investigate how service learning can be applied to countries with a universal healthcare system ethically, however, some limited research is available on how this can be implemented.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eThe review was not registered as it began as a student project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eDeclarations\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSupporting evidence\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupporting evidence can be found in the appendices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting Interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were fully involved in all stages of the project and contributed equally.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e1. Spencer J. Learning and teaching in the clinical environment. BMJ. 2003;326(1756\u0026ndash;1833 (Electronic)):591.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13(1):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e3. Miles S, Kellett J, Leinster SJ. Medical graduates' preparedness to practice: a comparison of undergraduate medical school training. BMC Medical Education. 2017;17(1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e4. Brennan N, Corrigan O Fau - Allard J, Allard J Fau - Archer J, Archer J Fau - Barnes R, Barnes R Fau - Bleakley A, Bleakley A Fau - Collett T, et al. The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors. Med Educ. 2010;44(1365\u0026ndash;2923 (Electronic)):449\u0026thinsp;\u0026minus;\u0026thinsp;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e5. Furco A. Service-learning: A balanced approach to experiential education. Revista Educaci\u0026oacute;n Global. 2011:64\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e6. Smith S, Thomas R, 3rd, Cruz M, Griggs R, Moscato B, Ferrara A. Presence and characteristics of student-run free clinics in medical schools. JAMA. 2014;10(1538\u0026ndash;3598 (Electronic)):2407-10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e7. Briggs L, and Fronek P. Student Experiences and Perceptions of Participation in Student-Led Health Clinics: A Systematic Review. Journal of Social Work Education. 2020;56(2):238\u0026thinsp;\u0026minus;\u0026thinsp;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e8. Wynne D, Cooper K. Students' perceptions of a UK physiotherapy student-led clinic. Clin Teach. 2023;20(1743-498X (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e9. Chin S, Richardson CA-O, Gardner A, Nazar HA-O. The impact and user experience of a student-led clinic providing preventative services. Int J Pharm Pract. 2024;32(2042\u0026ndash;7174 (Electronic)):237\u0026thinsp;\u0026minus;\u0026thinsp;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e10. Moseley J, Hellawell M, Graham C, Briggs A. Evaluation of a large group supervision model in a university student-led physiotherapy clinic. British Journal of Healthcare Management. 2022;28:61\u0026thinsp;\u0026minus;\u0026thinsp;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e11. NHSEngland. The NHS Long-term Plan. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e12. Stokel-Walker C. What can be done to ease today\u0026rsquo;s pressures in the NHS? BMJ. 2023;380:p88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e13. Ouzzani M, Hammady,H., Fedorowicz,Z., Elmagarmid, A.. Rayyan \u0026mdash; a web and mobile app for systematic reviews. Systematic Reviews. 2016;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e14. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e15. Bouzaher MH, Trinkle DB, Mutcheson RB. Interprofessional Service Learning in Medical Education: a Year-Over-Year Assessment of Student Feedback. Med Sci Ed. 2020;30(2156\u0026ndash;8650 (Electronic)):775\u0026thinsp;\u0026minus;\u0026thinsp;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e16. Burton E, Assi L, Vongsachang H, Swenor BK, Srikumaran D, Woreta FA, et al. Demographics, clinical interests, and ophthalmology skills confidence of medical student volunteers and non-volunteers in an extracurricular community vision screening service-learning program. BMC Medical Education. 2022;22(1):143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e17. Cappetto KD, Ehrlich B, Anderson EA, Huynh AT, Tran J, Hudon K. The benefits of undergraduate medical students delivering free preparticipation physical evaluations in collaboration with a K-12 school district. BMC Medical Education. 2024;24(1):901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e18. Carroll PH, J.. Development and evaluation of an interprofessional student-led influenza vaccination clinic for medical, nursing and pharmacy students. Pharm Pract. 2021;19(1885-642X (Print)):2449.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e19. Chen G, Kazmi M, Chen D, Phillips J. Improving Medical Student Clinical Knowledge and Skills Through Influenza Education. Med Sci Educ. 2021;31(2156\u0026ndash;8650 (Electronic)):1645-51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e20. Domaradzki J. 'Who Else If Not We'. Medical Students' Perception and Experiences with Volunteering during the COVID-19 Crisis in Poznan, Poland.. Int J Environ Res Public Health. 2022;19(1660\u0026ndash;4601 (Electronic)):2314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e21. Fukuma N, Reilly JM. Geriatrics Education: Phone Calls With Older Adults and Medical Students. Fam Med. 2023;25(1938\u0026ndash;3800 (Electronic)):471-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e22. Griswold AA-O, Klein JA-OX, Dusaj NA-OX, Zhu J, Keeler A, Abramson EL, et al. Students as Community Vaccinators: Implementation of A Service-Learning COVID-19 Vaccination Program. LID\u0026thinsp;\u0026minus;\u0026thinsp;10.3390/vaccines10071058 [doi] LID\u0026thinsp;\u0026minus;\u0026thinsp;1058. Vaccines (Basel). 2022;10(2076-393X (Print)):1058.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e23. Gummadi NA-OX, D'Amico M, Chandra P, Krumholz JO, Mumber HE, Hoyo L, et al. Impact of cuddler service-learning program in medical student education of opioid use disorder in pregnancy and neonatal opioid withdrawal syndrome. Substance Abuse. 2021;42(1547\u0026thinsp;\u0026minus;\u0026thinsp;0164 (Electronic)):951-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e24. Insley E, Tedesco K, Litman EA-O, Mangalapally N, Gicewicz C, Monaco-Brown ML. The NICU Cuddler Curriculum: A Service-Learning Curriculum for Preclinical Medical Students in the Neonatal Intensive Care Unit. MedEdPORTAL. 2021;17(2374\u0026ndash;8265 (Electronic)):11069.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e25. Kodweis KR, Allen RB, Deschamp EI, Bihl AT, LeVine DAM, Hall EA. Impact of student-run clinic participation on empathy and interprofessional skills development in medical and pharmacy students. Explor Res Clin Soc Pharm. 2023;11(2667\u0026ndash;2766 (Electronic)):100306.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e26. Lilliecreutz C, Holm ACS, Dahlgren MA, Blomberg M. Student-led clinic cervical cancer screening\u0026mdash;medical students\u0026rsquo; views on progression of learning, quality of Pap smears and women\u0026acute;s experiences of the visit \u0026ndash; a mixed methods study. BMC Medical Education. 2023;23(1):218.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e27. Lu WH, Pang L, Strano-Paul L. The Impact of COVID-19 Service Learning on Medical Student Professional Identity Formation. J Med Educ Curric Dev. 2024;11(2382\u0026thinsp;\u0026minus;\u0026thinsp;1205 (Print)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e28. McQuillan T, Wilcox-Fogel N, Kraus E, Ladd A, Fredericson M. Integrating Musculoskeletal Education and Patient Care at Medical Student-Run Free Clinics. PM R. 2017;9(1934\u0026thinsp;\u0026minus;\u0026thinsp;1563 (Electronic)):1117-21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e29. Mikhail H, Button B, LeBlanc J, Cervin C, Cameron E. Operation Remote Immunity: exploring the impact of a service-learning elective in remote Indigenous communities. BMC Medical Education. 2023;23(1):456.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e30. Milford E, Morrison K, Teutsch C, Nelson BB, Herman A, King M, et al. Out of the classroom and into the community: medical students consolidate learning about health literacy through collaboration with Head Start. BMC Medical Education. 2016;16(1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e31. Nghiem J, Liu M, Fruitman K, Zhou C, Zonana J, Outram T, et al. Exploring Preclinical Medical Students' Experience Facilitating Group Dialectical Behavior Therapy (DBT) for a Student-Run Mental Health Clinic: A Qualitative Study. Acad Psychiatry. 2024;48(1545\u0026ndash;7230 (Electronic)):334-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e32. Schutte T, Tichelaar J, Dekker RS, Thijs A, de Vries TPGM, Kusurkar RA, et al. Motivation and competence of participants in a learner-centered student-run clinic: an exploratory pilot study. BMC Medical Education. 2017;17(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e33. Server S, Uddin S, GoodSmith M, Zhang A, Sherer R, Lio J. Learning at a social distance: A medical student telehealth service for COVID-19 patients. MedEdPublish. 2016(2312\u0026ndash;7996 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e34. Shakartzi H, Wenren L, Fernandes S, Marino R, Meade M, Pierre-Joseph N, et al. DREAM: Empowering Preclinical Medical Students With Labor Support. MedEdPORTAL. 2018;14(2374\u0026ndash;8265 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e35. Smith SD, Yoon R, Johnson ML, Natarajan L, Beck E, Beck E. The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care. J Health Care. 2014;25(1548\u0026ndash;6869 (Electronic)):877\u0026thinsp;\u0026minus;\u0026thinsp;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e36. Ueberroth BE, Siegel DR. The Utility of EMRs in Student Run Clinics. The Clinical Teacher. 2020;17(2):159\u0026thinsp;\u0026minus;\u0026thinsp;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e37. Weber LC, Ortega JC, Bastea S, Robitz RA, Mumma BE. Women Leading Healthy Change: A Reciprocal Learning Experience for Women in the Sex Trade and Medical Students. MedEdPORTAL. 2021;17(2374\u0026ndash;8265 (Electronic)):11154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e38. Wong CK, Berens PM, Katta MV, Lie M, Fall D, Shah A, et al. From education to action: Development and evaluation of a student-directed service learning program. Med Teach. 2021;44(1466-187X (Electronic)):541-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e39. Burton E, Assi L, Vongsachang H, Swenor BK, Srikumaran D, Woreta FA, et al. Demographics, clinical interests, and ophthalmology skills confidence of medical student volunteers and non-volunteers in an extracurricular community vision screening service-learning program. (1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e40. Carroll PA-O, Hanrahan JA-O. Development and evaluation of an interprofessional student-led influenza vaccination clinic for medical, nursing and pharmacy students. (1885-642X (Print)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e41. Adel FW, Berggren RE, Esterl RM, Ratelle JT. Student-run free clinic volunteers: who they are and what we can learn from them. BMC Medical Education. 2021;21(1):356.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e42. Ryan M, Vanderbilt AA, Mayer SD, Gregory A. Interprofessional education as a method to address health needs in a Hispanic community setting: A pilot study. J Interprof Care. 2015;29(1469\u0026ndash;9567 (Electronic)):515-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e43. Byrne MA-OX, Alexander L, Wan JCM, Brown MA-O, Arora AA-O, Harvey A, et al. Clinical support during COVID-19: An opportunity for service and learning? A cross-sectional survey of UK medical students. Med Teach. 2023;45(1466-187X (Electronic)):859\u0026thinsp;\u0026minus;\u0026thinsp;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e44. Cohen A, Hu S, Bellon M, Wang NE, Sebok-Syer S. A lasting impact? Exploring the immediate and longitudinal impact of an emergency department service learning help desk program. AEM Educ Train. 2022;6(2472\u0026ndash;5390 (Electronic)):e10760.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e45. Smith Sd Fau - Yoon R, Yoon R Fau - Johnson ML, Johnson Ml Fau - Natarajan L, Natarajan L Fau - Beck E, Beck E. The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care. (1548\u0026ndash;6869 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e46. Janeway MG, Lee SY, Caron E, Sausjord IK, Allee L, Sanchez SE, et al. Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening. Am J Surg. 2020;219(1879\u0026ndash;1883 (Electronic)):346\u0026thinsp;\u0026minus;\u0026thinsp;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e47. Mishan L, Dragatsi D. Student-Run Clinics: A Novel Approach to Integrated Care, Teaching and Recruitment. Community Mental Health Journal. 2017;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e48. Shah NS, Rassiwala J, Ducharme-Smith AL, Klein DA, Kim AS, Leung C, et al. Development and evaluation of a service-learning model for preclinical student education in cardiovascular disease prevention. Adv Med Educ Pract. 2016;7(1179\u0026ndash;7258 (Print)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e49. Alzeera MA-O, Ward AA-O. Involving medical students in the planning and delivery of a vaccination and health screening outreach clinic. (1475-990X (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e50. Greer PJ, Jr., Brown Dr Fau - Brewster LG, Brewster Lg Fau - Lage OG, Lage Og Fau - Esposito KF, Esposito Kf Fau - Whisenant EB, Whisenant Eb Fau - Anderson FW, et al. Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine. (1938-808X (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e51. Chrisman-Khawam L, Abdullah N, Dhoopar A. Teaching health-care trainees empathy and homelessness IQ through service learning, reflective practice, and altruistic attribution. Int J Psychiatry Med. 2017;52(1541\u0026ndash;3527 (Electronic)):245\u0026thinsp;\u0026minus;\u0026thinsp;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e52. Rockey NG, Weiskittel TM, Linder KE, Ridgeway Jl, Wieland Ml. A mixed methods study to evaluate the impact of a student-run clinic on undergraduate medical education. BMC Medical Education. 2021;21(1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e53. Gimpel N, Kindratt T, Dawson A, Pagels P. Community action research track: Community-based participatory research and service-learning experiences for medical students. Perspect Med Educ. 2018;7(2212\u0026ndash;2761 (Print)):139\u0026thinsp;\u0026minus;\u0026thinsp;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e54. Ng KYY, Leung GYC, Tey AJ, Chaung JQ, Lee SM, Soundararajan A, et al. Bridging the intergenerational gap: the outcomes of a student-initiated, longitudinal, inter-professional, inter-generational home visit program. (1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e55. Laks J, Wilson LA, Khandelwal C, Footman E, Jamison M, Roberts E. Service-Learning in Communities of Elders (SLICE): Development and Evaluation of an Introductory Geriatrics Course for Medical Students. Teach Learn Med. 2014;28(1532\u0026ndash;8015 (Electronic)):210-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e56. Greer Jr PJ, Brown DR, Brewster LG, Lage OG, Esposito KF, Whisenant EB, et al. Socially accountable medical education: an innovative approach at Florida International University Herbert Wertheim College of Medicine. Academic Medicine. 2018;93(1):60\u0026thinsp;\u0026minus;\u0026thinsp;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e57. Schutte T, Tichelaar J, Donker E, Richir MC, Westerman M, van Agtmael MA. Clarifying learning experiences in student-run clinics: a qualitative study. BMC Medical Education. 2018;18(1472\u0026ndash;6920 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e58. Kalistratova VA-O, Nisanova AA-O, Shi LA-O. Student-run free clinics may enhance medical students' self-confidence in their clinical skills and preparedness for clerkships. Med Educ Online. 2024;29(1087\u0026ndash;2981 (Electronic)):2348276.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e59. Bamdas JAM, Averkiou P, Jacomino M. Service-Learning Programs and Projects for Medical Students Engaged With the Community. Cureus. 2022;14(2168\u0026ndash;8184 (Print)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e60. Phillips HE, Jennings RB, Outhwaite IR, Grosser S, Chandra M, Ende V, et al. Motivation to Impact: Medical Student Volunteerism in the COVID 19 Pandemic. Med Sci Ed. 2022;32(2156\u0026ndash;8650 (Electronic)):1149-57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e61. Modi A, Fascelli M, Daitch Z, Hojat M. Evaluating the Relationship Between Participation in Student-Run Free Clinics and Changes in Empathy in Medical Students. J Prim Care Community Health. 2017;8(2150\u0026thinsp;\u0026minus;\u0026thinsp;1327 (Electronic)):122-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e62. Fein AW, Paladine HL. Impact of a Student-Run Free Clinic's Women's Health Program on Perceived Readiness for Clinical Rotations. PRIMER. 2020;14(2575\u0026ndash;7873 (Electronic)).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e63. Hawkins N, Younan H-C, Fyfe M, Parekh R, McKeown A. Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on-call simulation. BMC Medical Education. 2021;21(1):165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e64. Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ, US: Prentice-Hall, Inc; 1986. xiii, 617-xiii, p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e65. Babiker A, El Husseini M, Al Nemri A, Al Frayh A, Al Juryyan N, Faki MO, et al. Health care professional development: Working as a team to improve patient care. Sudan J Paediatr. 2014;14(0256\u0026ndash;4408 (Print)):9\u0026thinsp;\u0026minus;\u0026thinsp;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e66. Lynn E, Byrne M. Balance Service and Learning: Insights From Volunteer Experiences of U.K. Medical Students During the COVID-19 Pandemic. Academic medicine : journal of the Association of American Medical Colleges. 2023;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e67. Carroll P, Sweeny K, Shepperd JA. Forsaking optimism. Review of General Psychology. 2006;10(1):56\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Service-learning, medical students, medical education, student-led clinics","lastPublishedDoi":"10.21203/rs.3.rs-9028837/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9028837/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eBackground\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eUndergraduate medical education has often been characterised by passive learning through observation. Despite medical education reforms including extended assistantships, newly qualified doctors report a lack of preparedness for practice. ‘Service learning’ is a form of education combining learning goals with community benefits. This systematic review explores the impacts of service learning on medical student participants with a view to informing implementation of this approach in supporting preparation for practice.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eUsing predefined search terms, Medline, Embase, Web of Science, PubMed and Education Research Complete databases were searched on 15.10.24 for studies between 2014-2024. Inclusion criteria were medical students, curricular service learning and service-learning involving patient care. \u0026nbsp;All papers were available in English. A reflexive thematic analysis identified common themes in papers, and a CERQUAL table was completed to ascertain confidence in these findings.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e50 papers were identified for inclusion. The studies covered a range of countries, and sample sizes. The methodology was primarily qualitative, with quantitative studies predominantly using Likert scales or pre/post designs.\u003c/p\u003e\n\u003cp\u003eSix themes identified were confidence, competence, social determinants, team-working, intrinsic motivation and professional identity. Confidence was the most frequently improved domain, particularly in performance of clinical assessment and communication skills. Whilst broadly positive, it was noted there was no change or a negative impact on empathy in 3 papers.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eService learning enhances medical education by increasing confidence, communication skills, cultural awareness, and teamwork. Student-led clinics have well-documented value in countries without universal healthcare; however a limitation was the low number of papers from outside N America. Many of the impacts were self-reported rather than observed. \u0026nbsp;While some students showed unchanged scores in empathy, service learning generally prepares students for clinical practice and working with underserved populations.\u003c/p\u003e","manuscriptTitle":"The impact of service learning on medical students: A systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:46:10","doi":"10.21203/rs.3.rs-9028837/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-26T13:00:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T17:00:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201052032053775608399026829589845709543","date":"2026-04-15T07:16:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140514684306201134395062628996001728396","date":"2026-04-08T11:56:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T05:35:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-13T12:23:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-13T02:03:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-13T02:03:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-04T09:50:11+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":"cf87b468-e2d1-43c3-af4b-2f3ef6eb830d","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T07:46:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:46:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9028837","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9028837","identity":"rs-9028837","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}