Qualitative analysis of a health systems science (HSS) course incorporating early clinical exposure

Abstract

Health systems science (HSS) is increasingly recognized as a core component of contemporary medical education. Although early clinical exposure (ECE) has been shown to enhance students’ understanding of clinical practice, evidence regarding its role in shaping HSS-related perspectives in Korean medicine (KM) education remains limited. This study explored how participation in an HSS-based ECE program influenced KM students’ perceptions and learning experiences. Between 2023 and 2025, a qualitative study was conducted with 65 third-year students enrolled in a KM college. Following HSS-oriented lectures and case-based discussions, the students participated in a 4-week observational ECE program in community-based KM clinics. Data were collected from reflective journals and analyzed using conventional qualitative content analysis with inductive coding. The derived codes were organized into themes and subsequently interpreted in relation to the core functional and foundational domains of HSS. Four overarching themes were identified: clinical practice competency, patient-centered care, health care systems, and professional competency. A total of 35 codes across 11 subcategories were derived. Students demonstrated an increased awareness of clinical processes, patient-centered approaches, and the broader health care system, including the influence of policies, organizational structures, and social determinants of health. Ethical considerations and professional responsibility were also prominently reflected in students’ experiences. Participation in the HSS-based ECE program was associated with an expanded understanding of clinical practice within broader health care contexts among KM students. These findings suggest that early experiential learning facilitates the development of systems-oriented perspectives and professional awareness. These results provide preliminary evidence that supports the integration of HSS-informed educational approaches into KM curricula.

1. Introduction

Traditional medical education has historically been structured around 2 primary pillars: basic medical sciences and clinical medicine.^[1] However, as health care environments become increasingly complex, medical practice can no longer be understood as a simple interaction between an individual physician and patient.^[2] Clinical decision-making and patient outcomes are shaped by broader contextual factors, including social determinants of health, health care policies, insurance systems, and organizational structures.^[3] Consequently, physicians are increasingly expected to develop integrative competencies that enable them to understand and navigate complex health care systems while maintaining a patient-centered professional identity.^[2]

In response to these challenges, health systems science (HSS) was introduced by the American Medical Association as a new conceptual framework for medical education.^[4] Defined as the “third pillar” of medical education, HSS complements basic and clinical sciences by emphasizing systems thinking, interprofessional collaboration, and the social context of health care.^[5] The HSS framework encompasses multiple competencies organized around systems thinking as a central integrative domain, aiming to foster holistic and patient-centered perspectives in future physicians.^[6] As a result, many medical schools in the United States now incorporate HSS education into clinical clerkships to better prepare students for contemporary health care practices.^[6]

In addition to HSS, early clinical exposure (ECE) has been recognized as an effective educational strategy for helping students understand the clinical environment and form professional identities before formal clinical training.^[7] ECE introduces students to hospital and community healthcare settings during the preclinical phase, encouraging them to reflect on how foundational medical knowledge, such as the basic sciences and anatomy, connects to physicians’ real-world roles.^[7,8] Previous studies have reported that ECE enhances students’ motivation for learning, understanding of clinical practice, and empathy toward patients.^[8,9]

In Korea, interest in HSS education has increased since 2022, particularly within medical education, with a focus on medical schools, and is accompanied by active discussions on curriculum reform. Korean healthcare education operates within a distinctive dual-medical system in which Western and Korean medicine (KM) are institutionally separated and taught independently.^[10] The Doctor of KM competency model emphasizes domains such as professionalism, communication, social accountability, and healthcare management, all of which inherently require holistic and systems-oriented thinking.^[11] Nevertheless, HSS has not yet been formally incorporated into the standard KM education curriculum, and system-based learning remains limited to indirect or fragmented educational activities.

Although previous studies in medical education have demonstrated that HSS and ECE independently contribute to the development of systems thinking and professional identity, empirical evidence regarding their integrated application in traditional KM education remains limited.^[6] Furthermore, few studies have explored how student experiential learning during ECE can be systematically interpreted through established HSS frameworks using qualitative methodologies.

Therefore, this study aims to explore how participation in an HSS-based ECE program shapes KM students’ perceptions and learning experiences, with particular attention paid to the emergence of system-oriented perspectives. By applying an inductive qualitative approach and subsequently mapping the derived codes onto the core and foundational HSS domains, this study sought to provide a structured understanding of how HSS-related competencies may begin to develop in the context of a dual healthcare system. In doing so, this study offers novel insights into the applicability of an HSS-informed educational design within KM and contributes to a broader discourse on integrating systems-based competencies into preclinical medical education.

2. Materials and methods

2.1. Study design

This qualitative study analyzed KM students’ reflective journals collected after their participation in an ECE program conducted prior to their clinical clerkships. The study was conducted from September 1, 2023, to August 31, 2025. Using the HSS framework, this study examined students’ reflections to explore their perceived educational effects, learning experiences, and the development of system-oriented perspectives.

2.2. Subjects

The participants were third-year students enrolled in a 7-year integrated Bachelor’s and Master’s program, consisting of a 3-year bachelor’s phase followed by a 4-year master’s phase. At the time of the study, the students were enrolled in the Medical Humanities – HSS course. They had not yet begun their clinical curriculum but had completed coursework in biomedical sciences and liberal arts during the first 3 years of the program. This course was the final course in the transition from the Bachelor of Science to KM. In this study, data from 2023 to 2025 were analyzed (n = 65). Patients and the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

2.3. Learning methods

2.3.1. In-class activities

Prior to participating in the ECE program, students received preparatory instruction from 3 faculty members (HYL, SI, and SWS) regarding the purpose and structure of the ECE program, as well as the concepts of HSS and systems thinking. Preparatory sessions consisted of lectures and case-based discussions, during which students analyzed clinical cases by identifying HSS-related domains embedded within each scenario. SI’s instructional involvement was limited to these preparatory HSS sessions conducted before the ECE placements; SI was not involved in supervising students during the subsequent community-based observational placements or in grading their reflective journals.

2.3.2. Early clinical exposure

Students participated in community-based observational placements at local KM clinics for 4 weeks (once per week, 3 hours per session). Ten community-based clinics were selected and invited through discussions among faculty members (SI, HYL, and SWS). No financial incentives were provided to participating clinics. Prior to the program, the faculty visited each clinic to explain the study’s purpose and the educational objectives of observational training.

Students were organized into approximately 10 to 12 groups, with each group consisting of 2 to 3 students, taking their preferences into account as much as possible. The clinics assigned for observation were determined by the instructor (HYL) and randomly allocated to each group. During the semester in which the Medical Humanities course was offered, students coordinated their schedules with assigned clinics and conducted observational training at mutually convenient times.

2.3.3. Reflective journal writing

The reflective journal template was provided to students in advance as part of the course materials. After each observational visit, students completed the reflective journal either by typing their responses electronically and printing the completed document or by handwriting their responses on a printed copy of the template. The completed journals were submitted in paper form to the course instructor (HYL). Students submitted 1 journal after each ECE session, resulting in 4 journal entries per student. The reflective journal included the following prompts.

“Please freely describe what you observed, learned, felt, and thought about in relation to Korean medicine knowledge and clinical skills.”

“Please freely describe what you observed, learned, felt, and thought about from the perspective of HSS.”

2.3.4. Group presentations

After completing the 4-week observational placement, students conducted a group presentation. The topics of the presentation were “students’ observations and reflections from the perspective of HSS” and “areas for further learning identified through their early clinical exposure.”

2.3.5. Data collection and analysis

This retrospective qualitative study examined students’ reflective journals following their participation in the ECE program. After all course grading had been completed, the course administrative assistant anonymized the submitted reflective journals by obscuring the section containing the students’ names. The anonymized paper documents were then scanned and converted into electronic files, and only the de-identified scanned copies were provided to the researchers (HYL, ARJ, and SI) for qualitative analysis. Data analysis was performed using conventional qualitative content analysis, emphasizing inductive category development as described by Hsieh and Shannon.^[12] The 3 researchers achieved data immersion by independently reviewing the journals multiple times to extract meaningful units of text. Initial codes were generated inductively and organized using Microsoft Excel, with in vivo coding utilized to maintain the authenticity of the students’ voices. Through recurring virtual meetings, the researchers iteratively compared, refined, and consolidated these codes into subcategories and overarching themes. Continuous reference to the raw data ensured that the emergent framework accurately represented the participants’ perspectives. Any discrepancies in categorization were resolved through collaborative discussion until a final consensus was reached (Table 1).

Table 1.

Theme – subcategory-code – representative quote.

Theme	Subcategory	Code	Representative quote
A. Clinical practice competency	Characteristics and roles of KM	Characteristics of KM	“When I visited a Western medical clinic for dizziness, I was told the cause was unknown and was simply prescribed medication without a clear explanation. In contrast, I appreciated that KM offered a more precise diagnosis and a clear treatment plan.”
		Roles of KM clinic	“I came to realize that a key part of being a KM doctor is knowing when acupuncture and herbal medicine are enough and when the patient should be referred to a higher-level hospital.”
		Clinical technique	“I learned that using a massage gun to stimulate painful areas was more effective and made it easier to locate the exact spots of pain than using hands alone.”
	Systems and practice management	Systems thinking	“Because some large KM hospitals have overused automobile insurance for profit, even legitimate claims have become restricted. This has negatively affected clinic management and led to reduced hiring, making it harder for future KM doctors to find jobs.”
		Clinical systems	“I was able to observe how the clinic improved efficiency by using systems such as outsourced herbal preparation, an appointment system, and pre-consultation questionnaires.”
		Clinical process	“New patients received consultation and treatment in the doctor’s office, while returning patients went straight to the treatment room and received care along with brief counseling.”
		Standardization	“I used to think that herbal prescriptions had to be completely different for every patient, but since many patients shared the same skin condition, I saw that some standardized herbal formulas were commonly used.”
		Health information systems	“I observed that the clinic actively used an electronic chart system, which improved efficiency in medical record keeping, accessibility to information, and convenience in patient management.”
		Environmental factors	“The doctor mentioned that more patients with joint pain visit the clinic on rainy days, and cases of rhinitis increase during seasonal changes.”
B. Patient-centered care	Patient-centeredness approach	Clinical attitude	“The nurses remembered each patient’s name and called them personally. During treatment, they talked comfortably with the patients…” “Since many patients visit the clinic regularly, I felt the importance of communicating kindly and consistently with every patient.”
		Patient-centeredness	“I think the most important thing is to make sure that patients do not feel uncomfortable during treatment and that they feel at ease throughout the process.”
		Individualized care	“I learned that even for the same condition, the choice of herbal ingredients can vary depending on each patient’s constitution.”
		Patient safety	“The doctor said he avoids using herbs or acupuncture points that could cause side effects in order to reduce medical accidents.” “He also informs the assistant of the exact needle locations after finishing acupuncture to prevent missed needle incidents.” “For patients taking herbal medicine for a long time, he regularly checks their liver function through blood tests.”
		Doctor–patient relationship	“I felt that when the relationship between the doctor and the patient is comfortable and trusting, the treatment becomes more effective, and patients seem more satisfied with their care.”
		Physical environment	“To improve patient comfort, the clinic had a spacious waiting area with massage chairs, and even a half-bath facility available for patients.”
		Family and social support	“Some patients visited the clinic alone without any guardian or family member.”
	Integrative and holistic approach	Holistic and integrative perspective	“I realized that when treating a patient, it is important not to look only at the body, but to consider their job, lifestyle, psychological state, and surrounding environment as well.”
		Integrative care	“I noticed that the doctor reviewed the patient’s prior treatments, clinical course, test results, and current medications from other hospitals, reflecting an integrative approach to care.”
C. Health care systems	Policy and management	Policy	“When KM doctors are allowed to use biomedical devices, many would likely purchase and incorporate them into practice, showing how treatment systems shift in response to health care policies.”
		Reimbursement/coverage	“It seemed essential for more treatment options to be included in insurance coverage so that a wider range of patients can access KM clinics.”
		Management	“Marketing was emphasized as an important part of clinic management, and the doctor explained that promotional methods have shifted from blogs in the past to YouTube more recently, and are now moving toward AI-based tools.”
	Health care organization and environment	Structure of KM clinic	“The clinic had separate spaces for each treatment field, and because many patients came by appointment, the waiting area did not seem to be used very much.”
	Social context and health service utilization	Health care delivery system	“During treatment, the doctor encountered a patient with suspected acute stroke and arranged transfer to the emergency room via 119. He emphasized that recognizing which patients need to be referred is a critically important competency.”
		Health care utilization decision	“A patient shared that they had been receiving both Western and Korean medical treatments, but after finding KM more effective, they now prefer KM alone. This showed how treatment experience strongly influences a patient’s choice of health care provider.”
		Socioeconomic factors	“The patient worked in a physically demanding job, so frequent injuries were unavoidable. It showed how a person’s social and occupational roles strongly influence their health care use.”
D. Professional competency	Learning and professional development	Goal setting	“Seeing that patients often asked questions not directly related to KM, I felt the need to study continuously so I could respond on the spot. Many of their questions were related to physiology, so I thought I should pay even more attention to studying physiology.”
		Professional development	“The doctor said that even after graduation, he continues to expand his knowledge by joining academic societies related to his treatment field or areas of interest, taking lectures, and reading various books.”
		Future career	“He recommended completing a 1-year internship, explaining that the process helps build essential competencies by learning about various parts of the medical system – such as radiology, clinical laboratory work, and administrative operations – and by gaining the ability to respond to different emergency situations.”
	Organization and leadership	Team work	“After the doctor finished the acupuncture treatment, the nurse removed the needles. It was clear that the clinical tasks were well divided among the staff.”
		Leadership	“Listening to the doctor talk about what must be considered when opening a clinic such as hiring staff and managing various situations that arise during clinical work, made me realize the responsibilities of a clinic director and the importance of leadership.”
		Self-leadership	“Since KM doctors often have to work evening hours and their work–life balance can be poor, the doctor said it is important to give oneself enough time off and rest. Looking at things from a long-term perspective is necessary to stay motivated and continue working over time.
	Professionalism and ethics	Ethical consideration	“The doctor explained that informing patients in advance about possible side effects or discomfort after treatment makes it easier to respond appropriately if an unexpected medical issue occurs.”
		Professional identity	“The doctor shared that he had invested a significant amount of money and effort into conducting toxicity tests on species such as medaka fish, mice, and pigs, and that the formulation had even passed evaluation by the Ministry of Food and Drug Safety.”
		Protection of privacy	“For patients with skin conditions who are uncomfortable exposing the affected areas, the clinic provided private single treatment rooms to ensure their privacy.”
	Awareness and reflections	Perception	“Among the various KM treatments, acupuncture seems to be widely preferred by the public, and as more clinical data accumulate showing its effectiveness, I felt that it has strong potential for further development in the future.”

AI = artificial intelligence, KM = Korean medicine.

Following the completion of the inductive analysis and finalization of the coding framework, a secondary interpretive step was conducted to map each code onto the established core functional and foundational HSS domains.^[6] This deductive mapping explored how empirically derived reflections aligned with theoretical HSS components, avoiding the use of predefined categories during the primary coding phase. The final alignment of 35 codes with the 7 core and 4 foundational domains is detailed in Table 2.

Table 2.

Code-core functional domains – foundational competency.

Code	Core functional domains	Foundational competency
Characteristics of KM	Health care structure and process patient, family, and community	Ethical and legal
Roles of KM clinic	Health care structure and process	Teaming, ethical, and legal
Clinical technique	Clinical informatics and health technology	Leadership, teaming
Systems thinking	Health care policy and economics value in health care Health system improvement	Ethics and legal, leadership
Health information management	Clinical informatics and health technology	Ethical and legal, teaming, change agency, management and advocacy
Clinical system	Health care structure and process Clinical informatics and health technology	Teaming, leadership
Clinical process	Health care structure and process	Teaming
Standardization	Health care structure and process	NA
Environmental factor	Population, public, and social determinants of health	Leadership, change agency, management and advocacy
Clinical attitude	Patient, family, and community	Ethics and legal
Patient-centeredness	Patient, family, and community	Ethics and legal
Individualized care	Patient, family, and community	Ethics and legal
Patient safety	Patient, family and community Health care structure and process	Ethics and legal, leadership, teaming
Physical environment	Health care structure and process	Leadership, teaming, ethics and legal
Doctor–patient relationship	Patient, family and community	Ethics and legal
Family and social support	Patient, family and community Population, public and social determinants of health	Ethics and legal
Integrative and holistic approach	Patient, family, and community Population, public and social determinants of health	Ethics and legal
Integrative care	Health care structure and process Patient, family, and community Population, public and social determinants of health	Ethics and legal; Leadership _ Teaming
Policy	Health care policy and economics	Change agency, management and advocacy Ethics and legal
Reimbursement/coverage	Health care policy and economics Value in health care	Change agency, management and advocacy; Ethics and legal
Management	Health care policy and economics	Leadership
Structure of KM clinic	Health care structure and process	Teaming
Health care delivery system	Health care structure and process	Teaming
Health care utilization decision	Patient, family, and community	NA
Socioeconomic factors	Patient, Family, and Community Population, public, and social determinants of health	NA
Goal setting	Health system improvement	Leadership
Professional development	Health system improvement	Leadership, teaming
Future career	Health care structure and process	Leadership
Teamwork	Health care structure and process Health system improvement	Teaming, leadership
Protection of privacy	Patient, family and community Health care structure and process	Ethics and legal
Leadership	Health system improvement	Leadership
Self-leadership	Health system improvement	Leadership
Ethical consideration	Patient, family, and community Health care policy and economics	Ethics and legal, teaming
Professional identity	Health system improvement	Leadership
Perception	Health care policy and economics; Patient, family, and community	Change agency, management and advocacy

KM = Korean medicine, NA = not applicable.

To ensure methodological rigor, this study adhered to the Standards for Reporting Qualitative Research.^[13] Credibility was established through investigator triangulation, with multiple researchers independently coding and discussing the findings. Dependability was maintained through a detailed audit trail of the analytical process, while confirmability was ensured by grounding the results in the original expressions of the students. Formal inter-rater reliability coefficients were not calculated. Instead, coding consistency was assessed through systematic comparison of the independently generated codes. When differences in coding or categorization arose, the researchers revisited the corresponding reflective data and discussed their interpretations until consensus was reached. Because 1 researcher (SI) who participated in the qualitative coding had also contributed to the preparatory HSS instruction, a robustness check was conducted to assess the potential influence of instructor involvement on the qualitative findings. The coding framework was reexamined after excluding SI’s coding, using the coding conducted by HYL and ARJ, and was compared with the final consensus framework derived from all 3 researchers.

3. Results

All 65 students successfully completed the ECE program, and reflective journals were obtained from all participants.

3.1. Theme and codes

Four overarching themes were identified: (A) clinical practice competency, (B) patient-centered care, (C) health care systems, and (D) professional competency (Table 1). Across these themes, we identified 11 subcategories and derived 35 codes. Each code was subsequently mapped to the core and foundational domains of the HSS.

3.1.1. Theme A: clinical practice competency

Through the ECE, students demonstrated an enhanced understanding of the characteristics of KM clinical practice, the roles of KM clinics, and KM clinical techniques (Table 1). They recognized that certain patient symptoms that could not be clearly explained within a Western medical framework could be interpreted from a KM perspective, and they became aware of the distinctive diagnostic and therapeutic approaches of KM in comparison with Western medicine. Students also came to understand that a key professional responsibility of KM physicians is not only to provide KM-based treatment, but also to determine when referral to higher-level medical institutions is appropriate based on the patient’s condition.

Students also observed various KM clinical procedures and operational systems, including appointment scheduling, electronic medical records, and standardized treatment processes. Through these observations, they recognized that clinical practice is shaped not only by physicians’ skills but also by organizational structures, information systems, and environmental factors, reflecting the emergence of systems-oriented perspectives in clinical settings.

3.1.2. Theme B: patient-centered care

Students developed perspectives on patient-centered care regarding clinical attitude, patient-centeredness, individualization, patient safety, physician-patient relationships, the clinic’s physical environment, and family and social support (Table 1). Specifically, the students observed health care professionals’ efforts to communicate kindly with patients and noted the importance of adopting communication styles that facilitate patient engagement. They also recognized the importance of attempting to understand situations from a patient’s perspective.

Students recognized that the clinical environment and the establishment of rapport between practitioners and patients influenced patients’ trust and satisfaction. Students recognized the importance of patient-centered communication, trust-building, and patient safety in clinical practice. They also reflected on the need to understand patients holistically by considering psychological, social, and lifestyle-related factors in addition to physical symptoms.

The students also recognized the necessity of understanding patients from an integrative and holistic perspective. They became aware that clinical care involved consideration not only of localized physical symptoms, but also of patients’ lifestyles, psychological states, social environments, and prior treatment experiences at other health care institutions. Through this realization, students came to understand that clinical practice is a process interconnected with multiple components of the health care system and is fundamentally delivered through a patient-centered approach.

3.1.3. Theme C: health care systems

The students’ reflections revealed a broader awareness of the health care system, including health care policies, institutional structures, and delivery systems. They recognized that factors such as insurance coverage, health care policies, and reimbursement systems influenced both physicians’ clinical practices and patients’ access to health care services (Table 1). Students also observed the role of KM clinics within the broader health care delivery system and the importance of collaboration with other health care institutions.

3.1.4. Theme D: professional competency

Students demonstrated an awareness of the competencies required by professionals, including professional development, professionalism and ethics, organization and leadership, and perceptions of KM. They recognized that all activities within a clinic should consider ethical and legal aspects (Table 1). For example, students noted that establishing an environment with a private room for patients who may experience exposure during treatment is an ethical practice aimed at protecting patient privacy. They also observed practices such as “informing patients in advance about possible adverse effects” and “a practitioner calling a patient after the consultation to check on the patient’s condition out of concern.” By observing these actions in clinical settings, the students reflected that medical practice goes beyond a simple sequence of diagnosis and treatment and involves developing a professional identity grounded in ethical responsibility.

3.2. Mapping of codes to HSS domains

Mapping the 35 codes to the core functional and foundational domains of the HSS framework demonstrated the multifaceted nature of students’ learning experiences during ECE (Table 2; Fig. 1).

Figure 1.

Comprehensive mapping of qualitative codes to HSS domains. HSS = health systems science.

3.3. Alignment with HSS core functional domains

Mapping the qualitative codes to HSS core functional domains identified “patient, family, and community” (n = 14) and “health care structure and process” (n = 13) as the most frequently represented categories. These were followed by “Health system improvement” (n = 7), “Health care policy and economics” (n = 6), and “Population, public, and social determinants of health” (n = 5). “Clinical informatics and health technology” (n = 3) and “Value in health care” (n = 2) were the least represented domains. The distribution of codes across the HSS domains is illustrated in Figure 1 and summarized in Table 2.

3.4. Alignment with HSS foundational domains

The distribution of foundational domains mapped to each code showed that “Ethics and legal” was the most frequent competency (n = 17), followed by “Leadership” (n = 15) and “Teaming” (n = 13). “Change agency, management, and advocacy” was identified in 5 codes (Table 2; Fig. 1).

Three codes (“Standardization,” “Health Care Utilization Decision,” and “Socioeconomic Factors”) were not mapped to a specific foundational competency. Although these reflections demonstrated students’ recognition of standardized clinical practices, factors influencing patients’ health care utilization, and the socioeconomic context of health, respectively, they primarily represented observations or awareness of these phenomena and did not provide sufficient evidence of the behaviors or competencies represented by the foundational HSS domains, such as leadership, teaming, ethical and legal competencies, or change agency, management, and advocacy.

4. Discussion

This study qualitatively analyzed reflective journals written by students from a KM college who participated in ECE, with the aim of examining the expansion of students’ perceptions following the practicum and identifying how these perceptions are associated with domains within the HSS framework. The findings suggest that ECE experiences, when analyzed from an HSS perspective, extend beyond mere observation of clinical techniques or procedural learning, contributing to a significant broadening of professional perception and holistic awareness among preclinical students. This suggests that ECE may function not only as an observational experience but also as a catalyst for the early cognitive restructuring of students’ conceptualization of clinical practice within broader health care systems.^[8]

The 35 codes derived from students’ reflective accounts illustrate how they interpreted their observations in KM clinics. Within the domain of clinical practice competency, the students recognized that the structural systems underlying clinical practice influenced both clinical efficiency and patient experience. For instance, they observed that elements such as the use of external herbal medicine preparation systems, appointment systems, pre-consultation questionnaires, electronic medical records, and differences in treatment sequences between new and returning patients contributed to improving clinical efficiency. This suggests that students came to understand that clinical efficiency is shaped not only by the physician’s knowledge and skill level but also by organizational structures and operational systems.^[2,6] In addition, the students recognized that the characteristics of the local community (e.g., a higher proportion of laborers and patients with musculoskeletal pain in areas near industrial sites) influenced the distribution of patient populations in KM clinics. In KM education, the principle of individualized treatment based on constitution and pattern identification is emphasized, even for the same disease.^[14] However, through clinical observation, students noted that relatively standardized prescriptions are often applied in real clinical settings, prompting them to reconsider their previously held dichotomous understanding that “treatment must be entirely different for each patient.” This can be interpreted as a process through which students recognize that KM practice involves the coexistence of individualization and standardization, suggesting that classroom-based knowledge can be flexibly reconstructed through clinical experience.^[8]

In the patient-centeredness domain, students demonstrated increased sensitivity to patients’ psychological and social contexts. They reflected on the importance of building rapport through a kind, attentive attitude, as well as the role of health care staff in creating a comfortable environment, such as remembering patients’ names and engaging in small talk. Through these observations, the students recognized that such attitudes influenced patients’ continued visits and treatment outcomes. In medical education, attitude is considered one of the most difficult domains for assessing knowledge, skills, and attitudes. Previous studies have reported that students’ levels of empathy tend to decline from the beginning of clinical clerkship^[14] and that the effects of educational interventions are often short-lived, highlighting the need for continuous exposure to experiential and reflective learning models throughout the curriculum.^[15] In this study, ECE appeared to contribute to students’ attitudinal development as part of the curriculum.

Notably, the most frequently identified code in the reflective journals was “holistic and integrative perspective,” which may reflect the fundamental principle of KM that emphasizes considering not only the localized symptoms but also patients’ lifestyle and overall constitution.^[16] As medical education increasingly shifts from a disease-centric to a patient- and lifestyle-centered paradigm,^[17] this inherent characteristic of KM may enable students to internalize holistic values in clinical practice.

Regarding health care system-related codes, students recognized that macro-level factors, such as policies, institutional frameworks, and social contexts, influence clinical practice. They identified the ability to determine when to refer patients to higher-level medical institutions as a critical competency, reflecting an understanding of both the interconnectedness of the health care delivery system and the professional responsibilities required by health care providers. Observations regarding differences in treatment choices based on insurance coverage, variations in institutional management, and promotional strategies further indicate that students began to recognize how policies, systems, and organizational structures shape the clinical environment. Given that a limited understanding of health policy among health care professionals may lead to passive responses to system changes and potentially compromise the quality of care,^[18] the importance of health policy education in medical curricula has been emphasized. Accordingly, ECE may serve as an opportunity to enhance students’ structural competency in macro-level health care contexts and foster critical reflection on the interaction between clinical practice and HSS.

In the domain of professional competency, students demonstrated awareness of ethical responsibility and their roles within health care organizations. By observing aspects such as patient safety, explanations of potential adverse effects, and protection of personal information, the students understood that medical practice involves responsibility and risk management. They also recognized that health care delivery operates within a team-based structure by observing the distribution of roles and collaboration among health care staff. Some students reflected on their future career paths and professional development, demonstrating their emerging ability to view their roles from a long-term perspective. These findings suggest that ECE can contribute not only to knowledge acquisition but also to the formation of professional identity.^[19,20]

Within HSS, core functional domains focus on how health care is delivered and how social contexts influence health, while foundational competencies provide the professional basis for effective collaboration, leadership, and ethical responsibility within complex health care systems.^[21,22] In our results, among the core functional domains, “Patient, family, and community” were most frequently represented, indicating that students began to understand patients not merely as individuals with disease, but as individuals situated within social, occupational, and community contexts. Reflections on repetitive injuries due to physical labor, seasonal variations in patient visits, and changes in health care utilization based on prior treatment experiences demonstrated that the students recognized the influence of social determinants on their health and clinical practice. These findings are consistent with previous studies suggesting that ECE enhances patient-centered values and professional identity formation through real-world clinical experiences.^[19,20] In this study, students not only understood the characteristics of KM practice but also recognized their responsibility to refer patients to higher-level institutions when necessary, thereby internalizing the professional role of primary care providers at an early stage. Notably, the most frequently represented foundational competency in this study was “ethics and legal,” reflecting students’ heightened awareness of professional responsibility, patient-centered values, and ethical considerations in clinical practice. In contrast, the frequency of “change agency, management, and advocacy” was relatively low. In HSS, this competency reflects the ability to identify system-level problems and contribute to improvements within the health care system.^[6,22] Given its complex, action-oriented nature, it may be difficult to develop this competency through short-term observational experience alone. Therefore, longitudinal and participatory educational approaches are important for its development. Furthermore, among the core functional domains, competencies related to the “Value in health care” are relatively underdeveloped. This domain encompasses the balance between health outcomes and the costs required to achieve them, including concepts such as cost-effectiveness and resource allocation.^[17] Given that such concepts are closely related to health economics and system-level evaluations, it is unlikely that students will fully grasp these high-level competencies through brief observational experiences in KM clinics alone. To enhance students’ understanding of the value of health care, educational experiences that extend beyond clinical settings to include exposure to health care-related institutions, such as the Health Insurance Review and Assessment Service, may be beneficial.^[18]

Although students demonstrated emerging systems-oriented perspectives, their reflections largely remained descriptive and were not yet fully developed into structured systems-thinking frameworks. While students recognized interactions among health care system components and broader contextual influences on clinical practice, more explicit and longitudinal educational strategies may be required to foster advanced systems-thinking competencies. These findings suggest that experiential exposure alone may be insufficient and should be supplemented by structured reflective and analytical learning activities.

While a previous study on the same ECE-based HSS program demonstrated significant improvements in students’ systems thinking through a quantitative evaluation, the present study extends these findings by qualitatively examining how such competencies emerge through clinical observations and reflections.^[20] By analyzing reflective journals, this study can uncover the specific cognitive processes and contextual nuances through which KM students internalize the details of the HSS domain that quantitative metrics often overlook. It provides a granular view of where systems thinking naturally emerges and requires structured pedagogical support.

However, despite its contributions, this study had several limitations. First, because the study was conducted at a single institution within a specific educational and cultural context, the transferability of the findings may be limited. Second, the data were derived from self-reported reflective journals, which may be subject to social desirability bias and may not have fully captured students’ actual learning processes. Third, the study relied solely on reflective journals without triangulation using other data sources such as interviews, direct observations, or faculty assessments, which may limit the depth and richness of the interpretation. In addition, participant checking (member checking) was not conducted; therefore, the researchers’ interpretations were not subsequently verified by the students, and some degree of interpretive subjectivity may remain. One researcher involved in qualitative coding had also participated in the preparatory HSS instruction, which may have introduced interpretive bias toward the intended educational outcomes. However, a robustness check excluding this researcher retained all 35 final codes, suggesting that the principal qualitative findings were not substantively dependent on the instructor-coder’s interpretation. Finally, although this study qualitatively explored students’ perceptions of ECE, it did not assess the longitudinal development or persistence of HSS-related competencies. Therefore, future research involving multicenter longitudinal designs and multiple data sources is needed to enhance the robustness of the findings, validate these qualitative themes across diverse educational settings, and examine the long-term impact of ECE on professional identity formation.

5. Conclusion

This study found that participating in ECE can foster competencies aligned with the HSS domains among KM students. A qualitative analysis of reflective journals suggests that through clinical exposure, students begin to recognize the interactions between health care policies, organizational structures, and social determinants of health. These findings provide preliminary evidence of the potential role of HSS-based perspectives in the KM curriculum in bridging the gap between theoretical knowledge and clinical practice. However, the descriptive nature of some reflections indicates that experiential exposure alone may be insufficient for students to develop advanced competencies in certain HSS domains. Therefore, improved curricula are required to effectively enhance these competencies. Additional research is required to validate these results in diverse settings and to evaluate their long-term impact on professional identity formation. In conclusion, this study provides a reference for how KM education can better align with the needs of system-based health care environments.

Acknowledgments

Gemini (Google) was used solely to assist in the visual design and formatting of Figure 1 to improve readability and presentation quality. No AI-generated scientific content, data analysis, interpretation, or conclusions were included, and all research content was developed exclusively by the authors.

Author contributions

Data curation: Aram Jeong, Sunju Im, Hye-Yoon Lee.

Conceptualization: Sunju Im, Hye-Yoon Lee.

Funding acquisition: Hye-Yoon Lee.

Methodology: Aram Jeong, Sang-Won Shin.

Project administration: Hye-Yoon Lee, Sang-Won Shin, Sunju Im.

Supervision: Hye-Yoon Lee.

Writing – original draft: Aram Jeong.

Writing – review & editing: Sunju Im, Sang-Won Shin.