Creating health systems citizens: enhanced professional identity formation through a para-curricular distinction track in health systems transformation and leadership

Abstract

Background

As healthcare systems grow increasingly complex, medical education must evolve to prepare future physicians to navigate and improve the environments in which they practice. Integrating Health Systems Science (HSS) into medical education is essential to equip learners with the mindset and skills needed to catalyze change and address systemic challenges. This transformation requires not only new knowledge but also the intentional development of a professional identity rooted in systems awareness and leadership.

Methods

The Brody School of Medicine established a three-year, longitudinal para-curricular program, the Health System Transformation and Leadership Distinction Track, known as Leaders in INnovative Care (LINC), starting the summer after the first year of medical school and continuing to graduation. LINC provides transformative curricular experiences that instill the HSS knowledge, skills, and mindset to develop students to become change agents and as future physician leaders for the changing environment. In-depth, semi-structured interviews of participants from the first two LINC cohorts were conducted to explore early impacts on participating students after completing the first year of this program. Qualitative analyses were conducted trom interview transcripts o determine emergent themes.

Results

All scholars (n = 15) were interviewed at the end of their first year in the program. Five key themes emerged: 1) increased critical thinking, 2) leadership, 3) developing awareness of HSS, 4) career trajectory, and 5) a sense of connectedness. Students reported adopting a systems thinking perspective on healthcare, recognizing the interrelated components of the system and their role as physicians within it. The development of advanced skills, a sense of connection, and leadership qualities were evident early in the program, with learners perceiving that they view healthcare differently than peers.

Conclusion

Themes from this study suggest that the LINC program fostered critical thinking, leadership, and a systems perspective early in training. Enhanced educational experiences in HSS can accelerate professional identity formation as change agents, with the potential for curricular expansion to include all medical students. Future efforts are needed for advancing assessments, tracking longitudinal outcomes, and collaborating across institutions to identify best practices in developing medical students as “systems-citizens.”

Background

Until recently, medical education in the United States has followed the structure established by the Flexner Report of 1910, consisting of four years of training after an undergraduate degree [1,2,3,4,5]. Traditionally, the first two years emphasized basic sciences, while the final two years focused on clinical training. However, as healthcare has evolved over the past century, these changes have led to a need for evolution in medical education [6,7,8,9]. Modern healthcare systems are increasingly complex, with a growing emphasis on improving quality, reducing costs, enhancing provider well-being, and achieving better outcomes for patients and populations. These shifts necessitate a transformation in medical education to equip future physicians with the skills to navigate and improve the systems in which they practice [6,7,8,9,10,11,12,13,14].

Health Systems Science (HSS) has emerged as the essential third pillar of medical education, complementing the traditional focus on basic and clinical sciences [11, 15, 16]. HSS encompasses the principles, methods, and practices that drive improvements in healthcare quality, efficiency, and patient outcomes within complex systems of care [15, 17]. By integrating concepts such as systems thinking, health policy, patient safety, and value-based care, HSS provides a cohesive framework that unifies previously fragmented systems-related competencies [17]. This integration is essential for catalyzing change, aligning medical education with societal needs, and ensuring that healthcare systems and educational structures evolve to meet the demands of modern patient care [17, 18].

Unlike basic and clinical sciences, which have traditionally emphasized fact-based learning and information delivery, HSS addresses not only critical content gaps, but also a deeper flaw in medical education’s focus on memorization and content acquisition [19, 20]. HSS intentionally cultivates systems thinking, collaboration, problem-solving, and the capacity to navigate ambiguity— skills essential to drive change in complex and evolving healthcare environments [21]. Effective HSS education requires both horizontal and vertical integration across the curriculum, ensuring students engage with these principles at multiple stages of their training and in various clinical contexts. To reinforce this learning, experiential strategies—such as interprofessional team training, quality improvement initiatives, and real-world clinical applications—are essential [11, 22]. These approaches not only enhance knowledge acquisition but also help students develop their professional identities as system-conscious physicians equipped to navigate and improve healthcare delivery [13, 23,24,25,26].

Recognizing the need for medical education reform, the American Medical Association (AMA) launched the Accelerating Change in Medical Educationinitiative in 2013, funding 11 medical schools to pioneer curriculum innovations with nearly half incorporating HSS curricula [13, 27, 28]. By 2016, the program expanded to 32 schools [29]. Several institutions have led the way in integrating HSS into medical education. For example, Penn State College of Medicine and the University of California, San Francisco launched major initiatives to create innovative, authentic curricula that integrated HSS competencies into the MD program, enhanced by early experiential roles within the healthcare system [30]. The Warren Alpert Medical School of Brown University introduced a required first-semester HSS course, incorporating clinical experiences such as a navigator program, free clinics, and homeless care initiatives [13]. Similarly, the University of Chicago Pritzker School of Medicine implemented the VISTA program—Value, Improvement, Safety, and Team Advocates—which includes hands-on interprofessional experiences, patient safety training, and cost-awareness initiatives [31]. Mayo Clinic’s Science of Health Care Delivery (SHCD) curriculum, required for all MD students since 2015, integrates online and in-person instruction across six domains—person-centered care, population-centered care, team-based care, high-value care, health care policy, and leadership—throughout the 4-year program, culminating in a certificate or optional master’s degree [32]. These efforts highlight a growing commitment to equipping future physicians with the skills necessary to navigate and improve complex health systems. However, expanding HSS education across all medical schools and into residency training remains a critical challenge to fully prepare students, trainees, and practicing physicians to meet the evolving needs of patients, healthcare systems, and society [33].

In addition to a longitudinal HSS curriculum for all medical students, the Brody School of Medicine at East Carolina University developed a three-year, longitudinal para-curricular program for up to 10 students per year. The Brody School of Medicine at East Carolina University, established by the North Carolina legislature in 1974, is a mission-driven medical school with a strong primary care orientation and an enrollment of approximately 86 MD students per year, dedicated to increasing the supply of primary care physicians, improving regional health, and training doctors to meet the healthcare needs of the state. The Health System Transformation and Leadership Distinction Track, known as Leaders in INnovative Care (LINC) Scholars, was designed to provide transformative learning experiences that instill the knowledge, skills, and mindset necessary to develop students to become change agents and as future physician leaders for the changing environment. The LINC program, described previously in the literature, begins with an intensive eight-week summer immersion, followed by longitudinal training woven throughout the remainder of medical school until graduation [34]. This structured experience prepares students to actively engage with and improve the healthcare systems in which they will practice.

Soon after launching the LINC program, we recognized the need for early evaluation to assess its impact on students'development. Anecdotal feedback suggested that the program was already shaping how students viewed healthcare systems, particularly in comparison to their peers. Given that HSS education was still emerging in medical training, we wanted to explore these early effects in more depth. Specifically, we sought to gather insights from the first two cohorts of LINC participants—about one-third of the way through their three-year program—to understand how their participation was influencing their professional identity and approach to their roles as future physicians.

With this study, we aimed to examine the early impact of the LINC program, focusing on how it shaped students'evolving perspectives on healthcare systems and their roles within them. By interviewing students at this early stage, we also sought to provide formative feedback to refine the program and contribute to the broader conversation on integrating HSS into medical education.

Methods

We conducted a qualitative study using a general inductive approach to create meaning from the data and determine themes [35]. We used semi-structured, audiotaped, interviews to elicit participants’ perceptions of their experiences in the LINC program.

The study team developed three research questions to evaluate interim outcomes. The first two questions were informed by anecdotal observations by participants as they moved through the M2 year: 1) How do LINC participants perceive differences between themselves and their classmates due to the LINC program? 2) What are additional impacts emerging from the participation in the LINC program? And the third was based on one of the general goals of forming distinction tracks of smaller groups of students within a medical school class, 3) Do LINC participants have a sense of community, networks, and connectedness (e.g. to peers, faculty, mentors, and health systems leaders) as a result of the LINC program? One investigator (SL) created an interview guide based on the research questions that was reviewed and refined by the research team (Table 1).

Table 1 Interview guide used for the face-to-face interviews with participants

A faculty member with experience in qualitative research (SC) and with minimal involvement in the LINC program was recruited to assist in design and to conduct the interviews. Two investigators (SL and SC) finalized the research questions and interview guide. IRB approval was obtained (UMCIRB 16–001458). Participants provided informed consent for participation and audio recording.

Over two academic years, fifteen semi-structured, face-to-face interviews of all LINC participants (Cohort 1 n = 5, Cohort 2 n = 10) lasting 30–60 min were conducted after completion of the first year of the program during the first clerkship of the M3 year. The interviews were transcribed verbatim and de-identified. The study sample was limited to the first two cohorts to capture early feedback and potentially to inform program changes prior to the start of the third cohort, and because analyses of the 15 transcripts suggested that no new themes were emerging.

Two investigators (SC and SL) reviewed all transcripts to generate initial codes, then a team of investigators (SL, LH, DL) analyzed three transcripts to iteratively develop the codebook. Further refinement was done after coding six additional transcripts and the final codebook was applied for all transcripts. After each transcript was reviewed multiple times by the three investigators, the team of coders met to discuss any discrepancies to allow creation of a final coded transcript. Selection of representative quotes occurred collaboratively through consensus of the three coders. Data were analyzed using NVivo software. (QRS International, Pty Ltd, v 12, 2018).

Results

The average age of participating students was 24.5 years. Four students were underrepresented minorities, and 6 were female. Two students had prior military experience, and 2 had advanced degrees. Characteristics of the participants are shown in Table 2.

Table 2 Demographic characteristics of participants

Qualitative analysis revealed five overarching themes that encapsulate the experiences and reflections of participants in the LINC program: Critical Thinking, Leadership, Developing Awareness, Career, and Connectedness. In the next section, each theme is presented with distinct subthemes, and illustrative quotes are provided representing each that provide further insight into the program's impact.

Critical thinking

Students perceived developing more in-depth critical thinking skills compared to their peers, encompassing three subthemes: 1) patient experience, 2) quality improvement, and 3) systems thinking.

Through an increased awareness of the patient perspective on the healthcare system, students identified the impact on quality and safety of care. One participant reflected, “So, it’s not only about a patient coming in… it’s about, how can I make that change for a patient and make sure that change is sustained? How can I make sure the patient is as comfortable as possible in the system?” (316). Another shared, “We did one thing in LINC that was pretty impactful. We shadowed the patients… just that experience alone changed my perception on things. I don’t know that all my colleagues and peers are doing that. Just because maybe they haven’t seen it from that lens.” (350).

Participants described an improved ability to both identify ways to solve problems and initiate a problem-solving process. One participant stated, “I think the LINC Program honed our skills on how to look at hospital problems and also helped me strengthen my confidence. … Now, the first time I’m in a hospital, I think, ‘Oh, we should fix that.’ I’m thinking QI project, PDSA cycle, little changes…” (350). Another emphasized the evolving mindset, “We will see or hear different attendings or residents talking about things that need to be changed, or things that need improvement in order to get the best quality outcomes. … I think that’s the first part in the process of shifting a mindset—having the conversation and being able to recognize when there is a problem. Then the next phase is figuring out ways that you could go about helping and improving those things. I think that we are looking at kind of healthcare with a different prism because of LINC.” (380).

Students reported thinking of healthcare from a systems perspective, recognizing the interconnectedness of components within the healthcare system. One noted, “I see the system in a different way than I think a lot of my classmates do… just in terms of understanding how the components fit together, and how many components there are. A lot of my classmates don’t have a great understanding. … I’ve got a better understanding of this system as it works and what pieces are changing, how those changes will affect the product that we deliver.” (379). Another highlighted the forward-thinking mentality fostered by the program, “… if we weren’t LINC scholars, it would be, ‘What specialty do you want to go into? What program do you want to apply to?’ But we are even going beyond that… thinking, ‘What system do you want to work under? Do we want to come up with our own measure for population health in our community? Do we want to get involved in different legislation to get our community to have more respect?’ It’s just… further beyond the thoughts of traditional third-year medical students.” (386).

Leadership

Participants described themselves as leaders and being recognized by their peers as leaders. They reported acknowledgment by peers and/or faculty for adding value to small group discussions through their additional knowledge related to health systems science (HSS). As one participant recounted, “A patient came in and had this complication in the health care system… So, everybody looked at me and said, ‘Let the LINC scholar do it.’ Another scholar (name removed) had the same exact experience—everybody looked at her like, ‘We’ll let the LINC scholar [do it], she knows about all quality improvement stuff, let her apologize.’” (316).

They also reflected on their personal growth and confidence in their leadership skills as a result of participating in LINC, with one participant stating, “I used to be a very passive leader. I think I’ve become more active… not being so embarrassed to do so, that’s just informally in sitting groups. … I’m more prone to say, ‘I will do it,’ than I used to be. Even in second year, I took a lot of leadership roles in the student interest groups.” (324).

Developing awareness

Participants voiced an increased awareness of aspects of HSS compared to their peers. They noted a greater realization of the importance of cost-conscious care, with one student sharing, “I’m thinking, ‘How much is this going to cost them? Do we really need that test or do we not? Are we ordering too much?’ So that’s changed my perspective on this.” (350).

Participants also emphasized the impact of structural and social determinants on health outcomes, stating, “It [LINC] definitely has given me a new perspective… especially where it would just create barriers to care, and that could be interpreted many different ways—be it nutrition, transportation, insurance, money, social economic status, or even where they live in town.” (370).

Participants expressed greater insight into the legislative and regulatory processes and the role of physicians as advocates. One noted, “I had never thought about how I would try to impact laws and state function as a private citizen… If you have that relationship with somebody, you can actually have an impact on how they might build, how they might think. Until I had that experience at the legislature, that was not something I knew existed.” (379).

Career

Compared to their peers, participants described recognizing the physician’s role as more comprehensive than making clinical decisions and providing direct patient care. They recounted developing a desire to take on administrative and leadership roles in their future training and careers. One participant reflected, “I came into school thinking that I would just be a doctor and help patients. … But I definitely see a bigger picture… being able to make more of an impact if I was one clinical doctor but also could be involved in hospital administration, or leadership roles, or something involved in QI.” (324). Another described their evolving mindset, “I just had not even thought about it… that we can have a system change, not just at the level of the hospital but policy too. It is just really broadened how I thought about our role as doctors and kind of what we are able to work towards.” (381).

They voiced seeing themselves as “change agents” who possessed the requisite knowledge and skills to empower them. Students expressed their desire to take on administrative and leadership roles in their future training and careers with one participant stating, “I am interested in administration [and] larger leadership roles. Likewise, it also encouraged me to jump into those leadership roles as soon as possible. So, I’m already thinking when I’m going to residency I’m going to be asking questions—‘Can I be involved in QI committees?’” (350).

Connectedness

Participants communicated having an increased network and connectivity to peers, faculty, mentors, and health systems leaders. They valued interactions with executive health system leaders, such as chief executive officers, chief quality officers, chief financial officer, and chiefs of service, etc. and reported this interaction enhanced their view of leader roles. It additionally exposed them to aspects of care delivery and administration they would not be routinely exposed to during medical school. One participant noted, “My most impactful [experience] was… going to a QI meeting… It was really impactful for me just because I had never known that those meetings happened, and all of the projects that they talked about… you can tell that everyone was very involved and wanted to be a high-quality center.” (324).

Participants appreciated the supportive environment provided by their peers, sharing, “It’s been a great experience and one of the things that really adds to it is that you’re going through it with about ten other people. So, you have this small core group of people that you can go ask or they can help you… just having that kind of small community there that supports you through it.” (358).

Mentorship was highlighted as critical to their development, with one participant noting, “Mentorship is huge. Just having a mentor that I can go out and have dinner or lunch with and just vent to that person all my issues, and [ask], ‘Hey, what should I do with my life?’ or all the questions that I have about the healthcare system.” (316).

Discussion

We conducted this qualitative study of LINC participants to examine potential early impacts of program participation, particularly regarding students'evolving perspectives on healthcare systems and their roles within them. Analyses revealed five overarching themes—critical thinking, leadership, developing awareness, career, and connectedness—that collectively reflect an early shift in professional identity toward becoming systems citizens. Rather than distinct competencies, these themes represent a broader mindset transformation—one in which students begin to see themselves as change agents within complex healthcare environments.

For over a century, medical education in the U.S. has followed the Flexnerian model, emphasizing scientific rigor and clinical competence. While transformative in its time, this model offered a limited view of the physician’s role. In the face of rising healthcare complexity and systemic challenges, there is growing recognition that physician training must evolve. HSS has emerged as a critical third pillar of medical education, complementing basic and clinical sciences. Recently emerging as central to HSS is the concept of the systems citizen—a modern redefinition of professionalism focused on systems awareness, collaboration, and stewardship to improve outcomes for patients and populations [25, 36].

Our findings suggest that the early, longitudinal exposure to HSS through the LINC program can contribute meaningfully to support this evolution. Students described thinking differently about healthcare systems—identifying inefficiencies, applying improvement science frameworks, and approaching care with a broader lens that incorporated patient experience, policy, and equity. These expressions of critical thinking extended beyond knowledge application; they reflected a growing comfort with ambiguity and a sense of responsibility for system-level outcomes.

Participants also described stepping into leadership roles—both formally and informally—as they contributed unique insights in small groups, led initiatives, or felt empowered to speak up during clinical experiences. Their perceived recognition as leaders by peers and faculty affirmed their growing identity as individuals capable of guiding systems change. This aligns with identity formation theories in which role internalization is shaped by authentic participation and social affirmation [37].

Equally important was the development of a systems-oriented awareness—particularly around cost, structural barriers, and social determinants of health. Students expressed a deeper understanding of the physician’s role in advocacy and policy, suggesting early formation of a professional identity that includes accountability for health equity and justice. These insights were often tied to experiences made possible through the LINC program—patient shadowing, legislative visits, and real-world exposure to healthcare operations.

Career aspirations among participants reflected a significant shift. While all planned to become practicing clinicians, many now envisioned themselves also holding administrative, quality improvement, or policy-influencing roles. This future-oriented mindset suggests that participants saw systems engagement not as an optional interest but as central to their careers as physicians. The longitudinal nature of the program, its mentorship model, and exposure to executive-level decision-makers likely reinforced this view.

A strong sense of connectedness also emerged as a critical support for identity formation. Students described their LINC cohort as a trusted peer group and valued the mentorship they received from faculty and health system leaders. These relationships offered psychological safety and modeled collaborative systems-based practice. This sense of belonging likely contributed to students’ confidence in adopting new roles and perspectives.

Taken together, these findings align with an evolving framework of professionalism that emphasizes identity formation over static traits or behaviors [13, 23]. Traditionally, professionalism in medical education has been conceptualized through virtue-based frameworks (focused on moral character) or behavior-based approaches (centered on observable competencies) [37]. While both perspectives offer value, they fall short in capturing the developmental process by which physicians internalize the values, commitments, and mindsets required to meet today’s healthcare challenges [38, 39]. The identity formation framework, by contrast, emphasizes the socialization of learners into the physician community through participation, reflection, and mentorship [39,40,41]. Within this view, systems citizenship emerges not merely as a set of competencies, but as a developmental outcome of professionalization—reflecting who students are becoming as physicians. The LINC program’s longitudinal structure, guided mentorship from health system leaders, and incorporation of real-world HSS experiences foster an environment conducive to early professional identity formation as systems citizens, as evidenced by students’ reflective insights after just one year in the program.

While promising, the integration of HSS in medical training—with the potential bonus of promoting systems citizenship— remains challenging. Barriers include mixed receptivity from faculty and learners, limited faculty development, and the absence of robust tools to assess systems-based learning and identity formation [22, 42,43,44]. Ultimately, as others have noted, the future of HSS education will depend on our ability to clearly define, promote, and evaluate its impact on learners and healthcare systems [17]. Despite these challenges, our qualitative study provides early evidence that immersive, longitudinal HSS experiences like LINC can cultivate this expanded professional identity at the undergraduate stage of medical training. The development of quantitative tools to assess systems citizenship, as well as multi-institutional studies to test the transferability and scalability of such programs, will be essential next steps. Although participants did not report increased stress related to their systems-focused identity, this remains an area for future exploration.

This study has several limitations. As a single-site qualitative study with a modest sample size, findings may not be generalizable and cannot determine causality. The timing of the evaluation was intentionally early to capture formative changes but does not assess longer-term outcomes such as career trajectory or leadership attainment. Additionally, some interview questions may have introduced bias by presuming change, and member-checking was not conducted due to concern about influencing participants’ ongoing development. Future work should include multi-institutional collaborations to examine whether similar HSS programs consistently foster similar components of systems citizenship. Longer-term follow-up will also be needed to evaluate how this identity manifests in physicians’ leadership, advocacy, and contributions to health system transformation.

Conclusion

The concept of the systems citizen offers a critical reframing of medical professionalism—one that aligns with the realities and demands of 21 st-century healthcare [13]. Optimizing health outcomes requires the intentional integration of HSS as the third pillar of medical education [13]. As healthcare systems grow more complex, physicians must be equipped not only with biomedical knowledge and clinical skills, but also with the systems thinking and leadership competencies necessary to improve care delivery at every level. The findings from our study emphasize the potential role of innovative curricula like the LINC program may play in shaping early professional identity as systems-minded physicians and leaders.

By fostering critical thinking, leadership capacity, and a deeper understanding of healthcare systems, programs like LINC can equip medical students to not only navigate but actively participate in the transformation of the healthcare landscape. Students reported gaining confidence, self-efficacy, and a broadened career vision that included advocacy, quality improvement, and administrative leadership. Mentorship and real-world experiential learning, hallmarks of the LINC program, were suggested to have enriched their professional development and cultivated a sense of connectedness with a supportive learning community. These outcomes underscore the transformative potential of immersive HSS programs in shaping physicians who are prepared to lead, collaborate, and innovate in complex and evolving healthcare environments. Medical schools have the opportunity to embrace curricular approaches that support the development of an expanded professional identity in order to equip learners with the needs of the populations and systems of care in which they will practice.