Exploring challenges in implementing a health systems science curriculum: a qualitative analysis of student perceptions

Objectives: Although a critical component of educational reform involves the inclusion of knowledge of and skills in health systems science (HSS) (including population health, health system improvement and high-value care) many undergraduate medical education programmes focus primarily on traditional basic and clinical sciences. In this study, we investigated students' perceptions of the barriers to, challenges involved in and benefits of the implementation of a HSS curriculum.

Methods: In 2014, we conducted 12 focus groups with 50 medical students across all years of medical school. Group interviews were audio-recorded and transcribed verbatim. We used thematic analysis to explore students' perceptions of a planned HSS curriculum, which was to include both a classroom-based course and an experiential component. We then identified themes and challenges from the students' perspective and agreed upon results and quotations.

Results: Students identified four barrier-related themes, including (i) medical-board licensing examinations foster a view of basic science as 'core', (ii) systems concepts are important but not essential, (iii) students lack sufficient knowledge and skills to perform systems roles and (iv) the culture of medical education and clinical systems does not support systems education. Students also identified several perceived benefits of a systems curriculum, including acquisition of new knowledge and skills, enhanced understanding of patients' perspectives and improved learning through experiential roles. The major unifying challenge related to students' competing priorities; one to perform well in examinations and match into preferred residencies, and another to develop systems-based skills.

Conclusions: Students' intrinsic desire to be the best physician possible is at odds with board examinations and desired residency placements. As a result, HSS is viewed as peripheral and non-essential, greatly limiting student engagement. New perspectives are needed to effectively address this challenge.