How do medical students learn about SDH in the community? A qualitative study with a realist approach

Abstract

Introduction

The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities.

Methods

A 4-week clinical practice program was conducted for 5^th- and 6^th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives.

Results

First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students’ confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings.

Conclusion

Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.

Keywords:

• Community health education; program evaluation; outcome and process assessment; social context; behavior mechanisms

Introduction

Social and environmental factors are known to have a substantial impact on health outcomes (Hood et al. 2016), but these factors appear little addressed in medical education (Lewis et al. 2020). Health is not determined solely by biological factors such as genes but is also influenced by socio-economic factors such as the individual's income, family situation, and connections with friends and acquaintances; and social factors such as the environment, including social relationships in the workplace and community (Galea et al. 2011). Referred to as the social determinants of health (SDH), these are well-established risk factors for poor health outcomes in vulnerable populations (Silverstein et al. 2019). Given the current situation of increasing social inequality, it is inevitable that healthcare professionals will come to serve as effective health advocates and valuable resources for the community (Marmot et al. 2008). However, the majority of healthcare professionals do not routinely identify or address the social needs of their patients in clinical practice (Fraze et al. 2019). Reasons for this failure to identify social needs include a lack of opportunity to understand their importance, limited time to discuss issues associated with SDH with patients, and a lack of opportunities to understand the various community resources available for problem-solving (Garg et al. 2009). Medical educators should therefore provide opportunities for medical students to learn about SDH based on the integration of clinical and social science knowledge and perspectives from other professions so that they can include it as one aspect of their future practice.

Practice points

• We developed a CBME curriculum to learn about SDH based on the threshold concept and identified four learning processes using a realist approach.

• Observational learning and explanations from role models.

• Cognitive dissonance that contradicted the medical model.

• Comparison of and verbalization of concrete experiences.

• Participation from a non-authoritative position which differed from the medical setting.

A U.S. survey on pre-licensure education for SDH found that education was more prevalent in the first and second years of medical school and that 34% of colleges reported it as a low priority (Lewis et al. 2020). The survey identified barriers to integrating SDH into the curriculum as including the idea that addressing SDH is originally outside the scope of physician responsibility; the difficulties of implementation in an already overcrowded curriculum; a lack of knowledge and skills among faculty required to teach it; and the difficulty of assessing SDH concepts in examinations (Lewis et al. 2020). A review of SDH education in post-licensure education identified a total of 12 studies but rated only half (50%) as achieving a positive program outcome (Hunter and Thomson 2019). Although improved program outcomes and greater opportunities to learn SDH have been reported, little mention has been made of the SDH learning process itself. In addition, reports have been limited to countries with frank differences in SDH, and few studies have appeared from countries where disparities are more difficult to see.

Therefore, we developed a well-designed CBME curriculum for learning SDH in Japan based on the threshold concept used for learning seemingly incomprehensible content (Meyer and Land 2005; Fredholm et al. 2020), as described below. However, it is not sufficient to evaluate such a complex educational program using unidirectional causal relationships. The realist approach has been offered in several theory-based evaluations developed within the social sciences (Pawson et al. 1997; Marchal et al. 2012; Wong et al. 2016). These reveal realities based on dynamism and context to better explain how and under what circumstances programs and interventions “work” in complex real-world systems, such as those associated with health care and research systems (Dalkin et al. 2015). Additionally, by adopting the realist approach that can confer both practice and policy advantages (Wong et al. 2012), this study aimed to identify patterns of the learning process used by medical students, the context they used them under, and the outcomes of their learning.

Methods

Study design

We used the realist approach, with an epistemology of realism that longitudinally examines the patterns of CMOs used by medical students to learn SDH from structural reports and observations, rather than a phenomenological realist position of a learning process that depicts the deep experience of medical students as the basis of cross-sectional realism (Pawson 2013). The realist approach aims to answer the question “what works, for whom, and in what circumstance?” with realism as the paradigm (Pawson and Tilley 2004). The realist approach differs from phenomenology, which is based on revealing individual experiences, and action research, which reveals changes in interventions. Rather, the realist approach highlights the ways in which the reasoning and actions of medical educators can help medical students function. As a method, the realist approach lies between positivism and social constructivism using several analysis methods. We, therefore, adopted thematic analysis (Braun and Clarke 2006), which is widely used in the analysis of inductive qualitative exploratory studies. In this study, we extracted themes that matched the CMOs.

Curriculum of medical students in Japan

Japanese medical schools enroll students after they have graduated from high school, and the curriculum is six years. In the second or third year, students begin their study of clinical medicine, including internal medicine and surgery, and by passing CBT (Computer-Based Testing) and OSCE (Objective Structured Clinical Examination) before clinical practice, they are awarded the title of student doctor and can start clinical practice. Clinical training at X University, which was used as the setting for this study, is conducted from October of the fourth year to June of the sixth year, for a total of 78 weeks. In the present study, we aimed to evaluate the university’s CBME curriculum with the aim of demonstrating the value of SDH as a compulsory program at the university.

CBME curriculum for learning SDH

We developed a CBME curriculum for learning SDH as an essential component of education for medical professionals in clinical practice. Every 4 weeks, 16–19 students participate in rotations: every 4 weeks, every student spent 1 week in a community clinic, 1–2 weeks in a community clinic or small hospital, 0–1 week in a community hospital, and 1 week in the family medicine department of X University Hospital. All facilities are located in suburban or rural areas. The prefecture in which University X is located has 197 doctors per 100,000 population, placing it 46th among 47 prefectures in Japan (Ibaraki Prefecture Government 2018). The training is conducted mainly in clinics and hospitals in towns with populations between 3,500 and 100,000 and includes areas where the individual clinics and hospitals are the only ones in that town. Residents who have lived in these rural areas are more likely to have poor health impacts due to social factors such as limited health care resources and low health literacy, as well as low socioeconomic factors, such as poverty (Rural Health Information Hub 2022). Additionally, in rural areas, the impact of these challenges can be magnified by pre-existing barriers, such as limited public transportation options.

The summative evaluation of students at each rotation site is based 70% on a performance observation evaluation at each site and 30% on a structural reflection report submitted on the last day. For the present study, the structural reflection report was one of the key pieces of data that revealed a series of CMOs. Formative evaluations are conducted through reflection at each rotation site and feedback through group discussion on the last day, and feedback is provided as appropriate. Further detail is provided in our previous papers (Ozone et al. 2020).

The learning theory on which the program for learning SDH has been based to date is termed “Threshold concepts.” This is a theoretical framework that explains how cognitive changes occur after a certain point of troublesome experience, and how what was previously incomprehensible becomes comprehensible to bring together different aspects of the experience. For example, SDH is difficult for students to understand in fundamental terms even if the faculty explain its concepts in class. Threshold concepts are adopted when we aim to reconstruct and/or transform students’ understanding of critical learning experiences, such as difficulties in understanding SDH concepts. Meyer and Rand identified the following characteristics of threshold concepts: transformative, irreversible, integrative, bounded, and troublesome (Meyer and Land 2003). Among these, “transformative” is a concept that changes the way students think about themselves and a discipline when they come to understand it; “irreversible” means that the student has to make a substantial effort to learn the concept, but once they learn it, they will never forget it; “integrative” means that it reveals previously hidden relationships about a subject – for example, once the student understands it, it will be possible to connect other fragmented concepts; “bounded” means that the contours of the learning objectives are made clear; and “troublesome” is a concept that is not intuitively understood, and which is where students stumble. Utilizing this “threshold concept,” we presented a framework of solid facts about SDH to allow it to be understood easily and prepared critical learning experiences using a rubric and structural reflection reports.

Study participants

For the present study, study participants were 5th- and 6th-year medical students who had completed the mandatory 4-week clinical practice in the CBME curriculum from September 2018 to May 2019 and September 2019 to March 2020.

Realist approach

First, we formulated a working hypothesis that we aimed to investigate in the program. Working hypotheses and theories about how complex interventions or programs work are formulated using deductive and inductive methods (Funnell and Rogers 2011). On this basis, using purposefully collected quantitative or qualitative data, we explored, tested, and refined what mechanisms work, under what conditions (context), with what interventions (including opportunities or resources), and from which explainable outcomes could be described and verified iteratively. This is described by the formula context + mechanism = outcome (following prior literature, the acronym context-mechanism-outcome is used to describe the components of CMOs) (Pawson et al. 1997). This heuristic is to remind us to think of realistic evaluation in terms of constructs; and not as formulas, as in mathematics.

Middle-range theory is a framework for thinking that is commonly applied to situations that meet certain conditions (Smith and Liehr 2013; Bolander Laksov et al. 2017). The middle-range is close enough to observed data to be incorporated into propositions that permit empirical testing (Merton and Merton 1968). More specifically, middle-range theory is an explanatory model that bridges, integrates and mediates the gap between empirical research based on small-scale working hypotheses and general theory (Merton and Merton 1968). In the realist approach, middle-range theory is often used as program theory and extracted in a way that predicts variations in mechanisms and related contexts in a number of relevant situations; and then formulates, tests, and refines variations in the outcome patterns. We then implemented the realist approach according to the four steps below, as first developed by Pawson (Pawson et al. 1997).

Generating a working hypothesis

To explore working hypotheses of how complex interventions or programs work as above, authors who had previously coordinated community health practice conducted annual program evaluations prior to this study. Based on the results, a CBME curriculum for learning SDH was developed and a working hypothesis emerged.

Hypotheses about the components of CMOs

Each element of a CMO was identified, namely the context, mechanism, and outcome. As background, Dalkin et al. classified the mechanisms or assumed mechanisms of programs/interventions/resources and, based on the equation of Pawson et al. – “Contexts + Mechanisms = Outcomes” (Pawson et al. 1997) – established the following equation: “Contexts + Mechanisms (programs/interventions/resources) → Mechanisms (assumption) = Outcomes” (Dalkin et al. 2015). This equation includes expected/unexpected mechanisms and what actually happens/doesn't happen in reality, as these are categorized as what is assumed or not and what is real or not. The patterns of CMOs can describe how multiple components of the program are integrated. To describe these patterns, we analyzed the structural reflection reports submitted by students on their last day in the program.

Observation and verification

The hypotheses and theories were tested by collecting quantitative and qualitative data on CMOs. A program evaluation was conducted based on the medical students' structural reflection reports, participant observations and SDH assignment worksheets. The authors, one of whom had previous experience with the realist approach (Haruta and Yamamoto 2020), discussed whether hypothesized middle-range theories on CMOs could comprehensively explain SDH learning in clinical practice per student year. To evaluate the consistency and integrity of the developed CMOs, we examined the validity of the theories for various relationships among CMOs.

Specifically, the authors initially shared the raw data in PDF format and used Excel to jointly conduct thematic analysis as a means of exploring the patterns of CMOs. Working hypotheses and CMOs were developed by three authors – JH, AT and SO – who extracted CMOs based on participant observations, the SDH assignment worksheet and structural reflection reports. Thematic analysis conducted on the first year’s data and these CMOs was further refined in the next year by these three authors and two other authors (TaM and TeM) (Braun and Clarke 2006).

Clarification of the theory

This process of validation and refinement led to a middle-range theory that revealed a series of CMOs that explained complex processes that were previously hidden in a ‘black box’, and the outcomes tied to them (Pawson and Manzano-Santaella 2012). We continued to test and refine the theory based on these 2019 and 2020 data. The authors reviewed the content and structure of the paper in accordance with the RMASESS II guideline (Wong et al. 2016). This study was approved by the Ethics Committee of the University.

Results

Working hypothesis

To create a working hypothesis, the authors and faculty members of X University evaluated the previous CBME curriculum based on medical students’ reports and responses from July to August 2018. In the process of program evaluation, the authors found little evidence of medical students learning SDH throughout the CBME curriculum because they did not have SDH as the main learning objective, and some rotating community medical sites had hardly dealt with it as a learning topic. Some faculty members also pointed out that it is important to explain the abstract concept of SDH to medical students based on specific cases, and that students should themselves identify issues during clinical practice that are connected to SDH. Based on these points, the following three factors were introduced to improve the CBME curriculum for learning SDH before September 2018.

First, because the concept of SDH is “troublesome” for faculty, several faculty development (FD) sessions were conducted before and during the CBME curriculum in which SDH was explained. Specifically, these FD sessions were designed to help faculty members understand the significance, purpose, and methods of SDH education in the CBME curriculum, and also to facilitate group discussions among them on the final session day. The main purpose of the sessions was to improve feedback from the faculty to medical students, with the aim of deepening their understanding of the SDH concept, such as facilitating their integration of experiences as medical students and their verbalization of these experiences.

Second, orientation for the medical students was held on the first day of the 4-week CBME curriculum. Further, a group discussion on experienced cases that were linked to SDH was held on the last day. During the orientation, the students were given a case-based lecture on SDH and an SDH assignment worksheet (Supplemental File 1) to complete during the 4-week clerkship. The SDH assignment sheet asked students to “select a patient or family member or laypeople you encounter during the 4-week rotation, and gather information and background factors that may be affecting SDH.” Reference material included 10 background factors related to SDH derived from the World Health Organization's Solid Facts 2nd edition (World Health Organization 2003), namely social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport. Using this assignment sheet to clarify learning objects, the students presented their SDH cases in group discussions, in which one faculty member acted as a facilitator for each group to contextualize the students' opinions while reinforcing them regarding their relevance to SDH.

Third, as a learner assessment, the medical students were asked to write a structural reflection report on SDH to clarify the boundaries of what they had learned. Through writing the report, the students were asked to describe “the significance of healthcare professionals' awareness of SDH” and “the role healthcare professionals should play in supporting community health.” The structural reflection reports were evaluated by two faculty members according to an evaluation rubric (Supplementary File 2), which was shared with students to guide them in their learning (Supplementary File 3).

On the basis of these discussions among faculty members, the CBME curriculum for learning SDH was launched in September 2018. A working hypothesis on how medical students can learn about the connection between society and medicine through a CBME curriculum for learning SDH was identified.

Testing and refining the hypotheses of CMOs

We enrolled 118 students who participated in the course from September 2018 to May 2019, 35 of whom were female. All reports were analyzed at this point. We also enrolled 101 students who participated from September 2019 to March 2020, 34 of whom were female. To validate the analysis, all reports were then further analyzed. After April 2020, the CBME curriculum was delivered online due to the coronavirus, and structural reflection reports associated with SDH could no longer be submitted. As a result of this process, four types of SDH learning patterns in the CBME curriculum were identified.

Patterns of configuration of CMOs

Four patterns of the configuration of CMOs emerged based on the above process. The following series of contest-mechanism-outcome is described in Table 1. In the interaction between the context of the student and the context of the local health care institution, multiple mechanisms functioned to result in outcomes that promoted awareness and evaluation in the learners. The mechanism (intervention) describes the learner's experience as extracted from the data, and the mechanism (reasoning) describes the learning theory as inferred from the data. Table 1 helps the reader understand the CMO patterns by explaining each pattern, and Table 2 describes representative data that we interpreted.

Table 1. Four patterns of a configuration of CMOs (Context, Mechanisms, and Outcomes).

	Context (students)	Context (local medical institutions)	Mechanisms (interventions)	Mechanisms (reasoning)	Outcomes
1	Experience of clinical practice in a university hospital where it is difficult to feel connected to the community and patients' lives	Encounters with role models who talk about the connection between the community and patient life and illness	Observations of physicians’ behavior and narratives making sense of that behavior in the community	Observational learning from role models and verbal explanation	Transformation to a comprehensive perspective on the person
					Significance of intervening as a group in behavioral practices upstream of disease
2	Thinking accustomed to conforming to the medical model	Exposure to a field where contradiction of facing what is not medically correct.	Cross-checking SDH with narratives of patients and surrounding stakeholders	Connecting SDH concepts with concrete experiences in a contradiction between their beliefs and observation	Awareness of the patient context with socioeconomic background upstream of the disease
3	Clinical practice where disease-labelled patients and communities are the learning objects	Practice that makes it easy for patients, families, lay people and communities to recall solid facts that are focused through prior learning.	Visits to patients and patient homes with difficult family and economic challenges reminiscent of SDH encountered in multiple regions	Chunking their experiences with SDH categories and comparison to concrete multiple regions and patients among peers’ experiences, and verbalization on the meaning of these experiences	Conceptual understanding of the impact of the interaction of socioeconomic factors
4	Probable context of the physician as an authority in the hospital.	Participated in the life situation of patients, families, and lay people in the community where the context is easily visible	Imagination of the continuity of time while linking socioeconomic factors and the living environment which is nurtured by understanding the specifics of patients, families, and lay people.	Fostering empathy through a non-authoritative position	Empathic understanding of contextualized patients

Table 2. Representative data was extracted from CMOs based on the medical students’ final reports.

1	Transformative learning brought about through observational learning and linguistic explanation from role models	Medical Student A “I felt that there is a way (to) watch over things like pachinko and cigarettes that make life worth living, without making them stop. I felt the importance of thinking about how we can support (local people's) way of life and what we should change and what we should not change.” Medical student B “An occupational physician I met told me that many of the patients he saw in the emergency room were suffering from a disordered lifestyle, and he wanted to become an occupational physician so that he could help them.” It seems that there were cases in which the results of health examinations improved and people were grateful for the total ban on smoking in the workplace. I think this can be implemented within the framework of the community. I think it is possible to grasp the characteristics involved in the health of the community in advance and give lectures and advice to them.
2	Consciousness of relationships with integrated solid facts achieved by confronting contradictions of the medical model.	Medical Student C “I found out that (the patients I met in the training) had become heavy smokers in the first place because they did not have literacy about the harmful effects of tobacco and because there were many smokers in their workplace, and as a result, they started smoking somehow, and even though they thought it was unhealthy, they had not been able to quit smoking for economic reasons. Without knowing the reasons for smoking in the first place, I felt I could not help this patient quit.” Medical Student D “There was the problem of losing your job if you were hospitalized, and deeper down there was the social context of the lack of educational development in the area, the fact that many people were employed in manual labor, and the lack of health awareness among the citizens because of smoking and drinking.”
3	Conceptual understanding framed by verbalization that clarified students’ experience associated with SDH	Medical student E “Some people lived in a dump, had mortgages and couldn't pay their electricity bills, while others lived in a beautiful house, with a wife who cleaned their rooms and prepared nutritious meals for them every day. Social disparity, stress, unemployment, food, and childhood all seem to be closely related and interrelated in the flow of being an individual. A poor environment also increases the risk of developing lifestyle and infectious diseases, while poor nutrition can lead to impaired immune function and physical ailments.” Medical Student F “A woman in her 40 s, who was responsible for all the household chores by herself, was suspected of relapsing into depression. Approaching only the current problems, such as lack of sleep and the burden of housework, will not lead to a solution, and the essential approach is to consider what the cause is. Why is the family situation such that she has to do both housework and work? What is the economic situation? Is there a community with society? Looking further upstream is especially important when there is no solution or no prospect of a solution.” Medical Student G “By educating children at an early age about the appropriate foods to eat, they will not only contribute to their growth process, but will also pass on the value of appropriate foods to their families as they grow up. If this nutrition education occurs in the entire community, it will contribute to the health of the entire community.”
4	Empathic understanding of human life within contexts fostered by participation in a local community that differ from the hospital context	Medical student H “We heard about a woman who came from outside the prefecture to live with her son. From a medical point of view, I felt that living together would make it easier for her to care for her son, and be safer and lead to better health. However, she said it was the hardest thing for her to leave her old friends and come to the new place where she didn't know anyone.” Medical Student I “By being aware of the individual, where they live and what kind of work they do, rather than labeling patients by age or gender with some kind of disease, we can think of the doctors who provide medical care as members of the community and colleagues who live in the same community. I felt that this was important.”

1. Transformative learning brought about through observational learning and explanation from role models.

2. Consciousness of relationships with integrated solid facts is achieved by confronting contradictions with the medical model.

3. Conceptual understanding framed by verbalization that clarified students’ experiences associated with SDH.

4. Empathic understanding of human life within contexts fostered by participation in a local community that differed from the hospital context.

The students had had little clinical experience with SDH as medical professionals. In the CBME curriculum, when they encountered physicians who talked about the connection between the lives of the community and patients through observational learning of their behavior and explanation with meaning-making narratives about SDH, they were able to transform their perspective, for example with regard to addiction, which is considered a disease under the medical model, and verbalize the significance of interventions for local communities in behavioral habits upstream of the disease. Through this experience, their perspective from the one-sided medical model was transformed, and their hitherto vague and conceptual understanding of SDH was deepened.

2. Consciousness of relationships with integrated solid facts achieved by confronting contradictions with the medical model

The students sometimes experienced a contradiction between their beliefs and observations about such matters as why some patients and/or lay people did not act in ways that were considered medically justified, such by smoking, drinking, and refusing hospitalization. SDH became apparent as a model to explain this. Relationships characterized by the integration of upstream socioeconomic factors and current behaviors allowed the students to associate indifferent socioeconomic factors with the behaviors of patients and laypeople, and make them conscious of these relationships.

3. Conceptual understanding framed by verbalization that clarified students’ experiences associated with SDH

The students explored patients or families or lay people with physical and/or mental and/or socioeconomic issues as learning objects in the community, where solid facts are easily visible, unlike the case in hospital settings where they are required to diagnose diseases. By encountering these types of SDH-related learning objects in multiple regions, chunking and comparison of information by similarity and association of concrete examples stimulated the development of SDH concepts. By labeling concrete experiences through verbalization in the group discussions and final structural report writing, students framed SDH in words as a concept that could be manipulated. Medical students were also meaningfully convinced that an approach based on SDH could be applied from individuals to the local community group.

4. Empathic understanding of human life within contexts fostered by participation in a local community that differed from the hospital context

In contrast to the hospital setting, where the context of the physician as the authority is implicit, the program allowed students to participate in the life situation of patients, families, and laypeople in the community. In a different position to that of a conventional physician who makes differential diagnoses and performs examinations and treatment, they were able to imagine the continuity of time while linking socioeconomic factors and the living environment. This process was nurtured by their understanding of the patients, families, and laypeople. As a result, they shed the mask of the authoritative physician and strengthened their empathic understanding of human life in society.

Discussion

In the CBME curriculum for learning SDH developed in this study, the perspective of the medical model was transformed into a life model through observational learning and explanations from role models in the community. The contradiction they experienced by holding two inconsistent views which had been hitherto incomprehensible was elicited and made concrete through the integrated explanation of solid facts, and the SDH concept was framed by verbalization. In addition, through participation in life situations from a non-authoritative standpoint, contextualized empathy for patients, families, and laypeople was fostered. The key findings of this process are discussed as follows.

First, role models lead to more effective learning than formal education (Glicken and Merenstein 2007). Students who have done their clinical training primarily in university hospitals may have learned to imitate doctors (Ricer et al. 1995). Although imitation is important for students' early adaptation to the clinical environment (Kenny et al. 2003), uncritical imitation may inhibit critical reflection and prevent students from addressing ethical norms (Paice et al. 2002). The observational learning and explanation from the role model physicians allowed the students to critically reflect on the previous medical model-centered physician. The presence of community role models who can inform medical students of the value of SDH provided them with the opportunity to reflect on biased perspectives within the medical models (Benbassat 2014).

Second, medical students are faced with the contradictions involved in dealing with issues in a non-medically correct way. These can be explained as instances of cognitive dissonance – a psychological concept defined by the stress a person experiences when presented with conflicting values, beliefs, or behaviors (Timmermans and Angell 2001; Nevalainen et al. 2010). Previous studies have identified confrontations with vulnerable people in emergency departments as one source of cognitive dissonance (Nevalainen et al. 2010). Such cognitive dissonance represents an attempt by the doctor to resolve the distress caused by changing their own values. For example, if cigarettes are medically harmful to the lungs but are a way of life for a 90-year-old patient, it is reasonable for the medical student to change their own perception. Consistent with previous literature (Lally and Cantillon 2014; Han et al. 2015), our medical students critically reflected on the social structure and healthcare system required to resolve those issues that elicited cognitive dissonance. The critical reflection that resulted from this process allowed the medical student to deepen their understanding of SDH.

Third, threshold concepts lead to a deeper understanding of conceptually challenging topics such as SDH (Neve et al. 2016). For example, medical students compared their concrete experiences in the community and verbalized the abstract conceptualization of SDH in an iterative manner, as well as the challenges they encountered in the community and the differences in their perceptions with peers (Cousin 2006). This learning experience – which can be explained as representative of a threshold concept – may lead to skilled clinicians who are able to explore and solve their own problems (Gaunt and Loffman 2018). These questions will be the subject of future research.

Fourth, medical students' contact with laypeople in local communities, in which they were not expected to play the role of ‘physician’ under the medical model, promoted an empathic understanding of human beings with connections between society and medicine. Some medical students might have increased their degree of cognitive empathy (Billington et al. 2007; Sulzer et al. 2016), thereby enabling them to recognize their experiences with impressive people for them in the community, share that understanding with others, and take effective action and act appropriately in a beneficial way (Pohontsch et al. 2018). CBME curricula may aid medical students in enhancing their faculty for cognitive empathy.

Several limitations of our study warrant mention. First, data collection was based on the hypothesis and theory developed by the authors, and thus a degree of selection bias may be present. To mitigate this, five authors critically examined the validity of these data and refined them iteratively. Furthermore, the CMOs were described to explain the context, allowing readers to transfer the findings to other settings, albeit the verification of CMOs developed in this study is required in other settings.

With regard to implementation, the learning patterns of socially engaged SDH may provide clues for developing medical curricula that require opportunities to teach social and behavioral science in medicine since this study presents findings that can be considered transferable to other contexts. Additionally, the SDH learning patterns have a significant international impact as a theoretical framework, even in situations such as Japan, where social disparities are difficult to see. Furthermore, when the faculty understands the threshold concepts that surround the essentially ambiguous and abstract nature of SDH, medical students may deepen their understanding of the connection between society and medicine. We hope that prescribing middle-range theories such as CMOs may lead to the reconstruction of a better SDH learning program in the changing community.

Conclusion

Using the realist approach, medical students were able to learn about the connection between society and medicine through four SDH learning patterns in the CBME curriculum, namely that observational learning and explanations formed role models that transformed the perspectives of medical students; cognitive dissonance triggered the exploration of SDH; conceptual understanding was achieved by verbalization; and empathic understanding deepened the understanding of SDH. The findings may contribute to the incorporation of required SDH learning into medical education.

Ethics approval statement

This study was approved by the Ethics Committee of the University of Tsukuba (approval number: 2676).

Glossary

Social determinants of health (SDH): Are the non-medical factors that influence health outcomes. Social determinants are the conditions under which people are born, grow, work, live, and age, and the broader forces and systems that shape the conditions of everyday life. These forces and systems include economic policies and systems, development issues, social norms, social policies, and political systems.

Community-based medical education (CBME): Refers to medical education that is based on clinical training in the community; CBME provides exposure to patients who are managing their illnesses in their homes, societies, and communities. Primary care clinicians and other health care providers accept learners in their own practices, professional communities, and local communities.

The realist approach: Is designed to answer questions such as “what works, for whom and under what circumstances?” based on a paradigm of realism between positivism and social constructivism.

Author Contributions

All authors were involved in the conception and design of this study. Data analysis was conducted by JH, AT and SO, and was further refined by all authors. JH mainly wrote the paper. The other authors then revised it critically for intellectual content, and all of them approved the paper.

Acknowledgments

The authors would like to thank all the students who participated in this study. We also thank all our department faculty members who contributed to student education and data collection.

Disclosure statement

The authors declare that they have no conflict of interest.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by JSPS KAKENHI Grant Number JP19K10527.

Notes on contributors

Junji Haruta

Junji Haruta, MD, PhD, is Associate Professor, Medical Education Center, School of Medicine, Keio University, Tokyo, Japan and Visiting Associate Professor, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Ayumi Takayashiki

Ayumi Takayashiki, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Sachiko Ozone

Sachiko Ozone, MD, PhD, Department of Family Medicine, General Practice and Community Health, Faculty of Medicine, University of Tsukuba, Japan.

Takami Maeno

Takami Maeno, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Tetsuhiro Maeno

Tetsuhiro Maeno, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.