Unpacking Medical Students' Mixed Engagement in Health Systems Science Education

Phenomenon: Medical education is better aligning with the needs of health systems. Health systems science competencies, such as high-value care, population health, and systems thinking, are increasingly being integrated into curricula, but not without challenges. One challenge is mixed receptivity by students, the underlying reasons of which have not been extensively explored. In this qualitative study, we explored the research question: "How do students perceive health systems science curricula across all four years, and how do such perceptions inform the reasons for mixed quality ratings?" Approach: Following large-scale health systems science curricular changes in their medical school, we used students' open-ended comments obtained from course evaluations related to 1^st-, 2^nd-, and 4^th-year courses and performed a qualitative thematic analysis to explore students' perceptions. We identified themes, synthesized findings into a conceptual figure, and agreed upon results and quotations. Findings: Five themes were identified: (1) perceived importance and relevance of health systems science education, (2) tension between traditional and evolving health systems science-related professional identity, (3) dissatisfaction with redundancy of topics, (4) competition with basic and clinical science curricula, and, (5) preference for discrete, usable, testable facts over complexity and uncertainty. The relationship between themes is described along a continuum of competing agendas between students' traditional mindset (which focuses on basic/clinical science) and an emerging medical education approach (which focuses on basic, clinical, and health systems science). Insights: Health systems science education can be viewed by learners as peripheral to their future practice and not aligned with a professional identity that places emphasis on basic and clinical science topics. For some students, this traditional identity limits engagement in health systems science curricula. If health systems science is to achieve its full potential in medical education, further work is required to explore the adoption of new perspectives by students and create activities to accelerate the process.