{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T11:58:20Z","timestamp":1785499100118,"version":"3.56.0"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T00:00:00Z","timestamp":1785456000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Family Medicine and Primary Health Care anchor effective health systems, yet undergraduate curricula have given them limited dedicated space. The COM353 Family Medicine and Primary Care block at Alfaisal University was created to give these areas more dedicated curricular space, combining didactic teaching, Primary Health Care Center (PHCC) visits, structured reflection, and explicit engagement with clinical uncertainty.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a single-institution, cross-sectional quantitative evaluation of third-year medical students who completed the block in January 2026. A 42-item Likert instrument, adapted from the Dundee Ready Education Environment Measure (DREEM) and the Groningen Reflection Ability Scale (GRAS) with block-specific items, captured perceptions across seven domains. Of 126 enrolled students, 96 responded (76.2%). Analyses included descriptive statistics, internal-consistency reliability, inter-domain correlations, and multiple linear regression. Reporting follows the STROBE guideline.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Domain means ranged from 3.90 to 4.27 (of 5), with all domains exceeding the scale midpoint by large margins (Cohen\u2019s d, 0.92 to 1.58). Agreement rates ran from 63.7 to 80.7%. Internal consistency was excellent (Cronbach\u2019s alpha\u202f=\u202f0.988 overall; 0.940 to 0.974 across domains). Family Medicine and PHC Competencies achieved the highest mean (4.27) and reflective practice the lowest (3.90). On a single global rating, 87.5% of students rated the block positively (mean 3.80, SD 1.13). Multiple regression with six domains predicting perceived block value explained 78.2% of variance;\n                      <jats:italic>F<\/jats:italic>\n                      (6, 89)\u202f=\u202f53.25,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001. Three domains independently predicted overall evaluation: Systems Thinking (beta\u202f=\u202f0.727,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001), Reflection (beta\u202f=\u202f0.295,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.002), and Learning Environment (beta\u202f=\u202f0.293,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.013). Despite producing the highest absolute scores, Family Medicine Competencies did not independently predict overall evaluation, likely reflecting shared variance with Systems Thinking (r\u202f=\u202f0.874).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>A purposefully integrated Family Medicine block joining community-based experience, reflective practice, and explicit work with uncertainty appears to produce favorable educational outcomes across multiple domains. Of these, perceiving healthcare as an interconnected system most strongly predicted students\u2019 overall evaluation, suggesting that systems thinking acts as the integrative thread giving other curricular elements coherence.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1870311","type":"journal-article","created":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T11:10:25Z","timestamp":1785496225000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Systems thinking as the integrative competency in undergraduate Family Medicine education: a cross-sectional evaluation of an integrated primary care block"],"prefix":"10.3389","volume":"13","author":[{"given":"Abdul Rehman Zia","family":"Zaidi","sequence":"first","affiliation":[{"name":"Department of Family and Community Medicine, College of Medicine, Alfaisal University","place":["Riyadh, Saudi Arabia"]},{"name":"School of Kinesiology and Health Science, York University","place":["Toronto, ON, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baraa","family":"Alghalyini","sequence":"additional","affiliation":[{"name":"Department of Family and Community Medicine, College of Medicine, Alfaisal University","place":["Riyadh, Saudi Arabia"]},{"name":"Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto","place":["Toronto, ON, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Racha Kamal","family":"Khaled","sequence":"additional","affiliation":[{"name":"Department of Family and Community Medicine, College of Medicine, Alfaisal University","place":["Riyadh, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad Ameen","family":"Alswes","sequence":"additional","affiliation":[{"name":"Department of Family and Community Medicine, College of Medicine, Alfaisal University","place":["Riyadh, Saudi Arabia"]},{"name":"Department of Family Medicine, King Faisal Specialist Hospital and Research Center","place":["Riyadh, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen P.","family":"Batty","sequence":"additional","affiliation":[{"name":"Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto","place":["Toronto, ON, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,31]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"e049825","DOI":"10.1136\/bmjopen-2021-049825","article-title":"Medical students' experience of the hidden curriculum around primary care careers: a qualitative exploration of reflective diaries","volume":"11","author":"Parekh","year":"2021","journal-title":"BMJ Open"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"2306936","DOI":"10.1080\/13814788.2024.2306936","article-title":"The revised European Definition of General Practice\/Family Medicine. A pivotal role of One Health, Planetary Health and Sustainable Development Goals","volume":"30","author":"Windak","year":"2024","journal-title":"Eur J Gen Pract"},{"key":"ref3","volume-title":"The European Definition of General Practice\/Family Medicine: 2023 Edition","year":"2023"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1111\/j.1468-0009.2005.00409.x","article-title":"Contribution of primary care to health systems and health","volume":"83","author":"Starfield","year":"2005","journal-title":"Milbank Q"},{"key":"ref5","volume-title":"Declaration of Astana. Global Conference on Primary Health Care, Astana, Kazakhstan","year":"2018"},{"key":"ref6","volume-title":"Operational Framework for Primary Health Care: Transforming Vision into Action","year":"2020"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"e008265","DOI":"10.1136\/bmjopen-2015-008265","article-title":"Impact of family medicine clerkships in undergraduate medical education: a systematic review","volume":"5","author":"Turkeshi","year":"2015","journal-title":"BMJ Open"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"1666718","DOI":"10.3389\/fmed.2025.1666718","article-title":"Undergraduate medical education amidst volatility, uncertainty, complexity, ambiguity","volume":"12","author":"Camarata","year":"2025","journal-title":"Front Med"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"285","DOI":"10.22454\/FamMed.2022.947719","article-title":"Medical students\u2019 reactions to uncertainty during clinical rotations","volume":"54","author":"Kerr","year":"2022","journal-title":"Fam Med"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1163","DOI":"10.1111\/medu.14873","article-title":"Improving uncertainty tolerance in medical students: a scoping review","volume":"56","author":"Patel","year":"2022","journal-title":"Med Educ"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1016\/j.socscimed.2017.03.024","article-title":"Tolerance of uncertainty: conceptual analysis, integrative model, and implications for healthcare","volume":"180","author":"Hillen","year":"2017","journal-title":"Soc Sci Med"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"23821205221091511","DOI":"10.1177\/23821205221091511","article-title":"Implementing Kolb's experiential learning cycle by linking real experience, case-based discussion and simulation","volume":"9","author":"Wijnen-Meijer","year":"2022","journal-title":"J Med Educ Curric Dev"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"1399","DOI":"10.1186\/s12909-024-06401-2","article-title":"Medical students\u2019 perspectives of reflection for their professional development","volume":"24","author":"Heydari","year":"2024","journal-title":"BMC Med Educ"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"e84406","DOI":"10.2196\/84406","article-title":"Impact of community-oriented medical education on medical students' perceptions of community health care: qualitative study","volume":"12","author":"Shikino","year":"2026","journal-title":"JMIR Med Educ"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1186\/s12909-023-05004-7","article-title":"Students' perception of the educational environment at King Saud bin Abdulaziz University for Health Sciences using DREEM tool","volume":"24","author":"Awawdeh","year":"2024","journal-title":"BMC Med Educ"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"214","DOI":"10.1186\/1472-6920-14-214","article-title":"A validation study of the psychometric properties of the Groningen reflection ability scale","volume":"14","author":"Andersen","year":"2014","journal-title":"BMC Med Educ"},{"key":"ref17","volume-title":"Statistical Power Analysis for the Behavioral Sciences","author":"Cohen","year":"1988"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1097\/ACM.0000000000000951","article-title":"Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences","volume":"92","author":"Gonzalo","year":"2017","journal-title":"Acad Med"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"53","DOI":"10.5116\/ijme.4dfb.8dfd","article-title":"Making sense of Cronbach's alpha","volume":"2","author":"Tavakol","year":"2011","journal-title":"Int J Med Educ"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1002\/ase.2345","article-title":"Survey response rates in health sciences education research: a 10-year meta-analysis","volume":"17","author":"Wilson","year":"2024","journal-title":"Anat Sci Educ"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1290","DOI":"10.1080\/0142159X.2023.2216863","article-title":"Psychological safety in medical education: a scoping review and synthesis of the literature","volume":"45","author":"McClintock","year":"2023","journal-title":"Med Teach"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"699","DOI":"10.4300\/JGME-D-15-00719.1","article-title":"Does psychological safety impact the clinical learning environment for resident physicians? Results from the VA'S learners' perceptions survey","volume":"8","author":"Torralba","year":"2016","journal-title":"J Grad Med Educ"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"2786","DOI":"10.4103\/jfmpc.jfmpc_917_23","article-title":"Three years versus four years Saudi board family medicine program: graduates' academic performance, perceptions, burnout, and satisfaction with professional life","volume":"12","author":"Almutairi","year":"2023","journal-title":"J Family Med Prim Care"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"95","DOI":"10.4103\/jnsm.jnsm_141_22","article-title":"Preparedness to implement \u201ca family physician for every family,\u201d which is the magic recipe for cost-effective health care for all: viewpoint","volume":"6","author":"Alshammari","year":"2023","journal-title":"J Nat Sci Med"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"e1340","DOI":"10.3109\/0142159X.2013.806981","article-title":"A review of longitudinal community and hospital placements in medical education: BEME guide no. 26","volume":"35","author":"Thistlethwaite","year":"2013","journal-title":"Med Teach"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1007\/s11845-020-02260-0","article-title":"Career destinations of graduates from a medical school with an 18-week longitudinal integrated clerkship in general practice","volume":"190","author":"Glynn","year":"2021","journal-title":"Ir J Med Sci"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1186\/s12909-022-03107-1","article-title":"It's how we practice that matters: professional identity formation and legitimate peripheral participation in medical students: a qualitative study","volume":"22","author":"Orsmond","year":"2022","journal-title":"BMC Med Educ"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"1098","DOI":"10.1080\/0142159X.2019.1630730","article-title":"Experience based learning (ExBL): clinical teaching for the twenty-first century","volume":"41","author":"Dornan","year":"2019","journal-title":"Med Teach"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"531","DOI":"10.22454\/FamMed.2018.634768","article-title":"A pilot study to address tolerance of uncertainty among family medicine residents","volume":"50","author":"Taylor","year":"2018","journal-title":"Fam Med"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"2408","DOI":"10.1007\/s11606-020-06538-y","article-title":"Tolerance for uncertainty and professional development: a normative analysis","volume":"36","author":"Reis-Dennis","year":"2021","journal-title":"J Gen Intern Med"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"543","DOI":"10.14744\/SEMB.2023.52223","article-title":"Factors affecting the level of reflective thinking and clinical decision-making skills in medical faculty students","volume":"57","author":"Hafiz","year":"2023","journal-title":"Med Bull Sisli Etfal Hosp"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"430","DOI":"10.4300\/JGME-D-16-00500.1","article-title":"Reflection as a learning tool in graduate medical education: a systematic review","volume":"9","author":"Winkel","year":"2017","journal-title":"J Grad Med Educ"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"718","DOI":"10.1097\/ACM.0000000000000700","article-title":"A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators","volume":"90","author":"Cruess","year":"2015","journal-title":"Acad Med"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"1438082","DOI":"10.3389\/fmed.2024.1438082","article-title":"Being, becoming, and belonging: reconceptualizing professional identity formation in medicine","volume":"11","author":"Sternszus","year":"2024","journal-title":"Front Med"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"1661","DOI":"10.1016\/S0140-6736(08)61690-6","article-title":"Closing the gap in a generation: health equity through action on the social determinants of health","volume":"372","author":"Marmot","year":"2008","journal-title":"Lancet"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"596","DOI":"10.1016\/j.amjmed.2023.03.001","article-title":"System citizenship: re-envisioning the physician role as part of the sixth wave of professionalism","volume":"136","author":"Gonzalo","year":"2023","journal-title":"Am J Med"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1186\/s12909-020-02442-5","article-title":"Designing health professional education curricula using systems thinking perspectives","volume":"21","author":"Khanna","year":"2021","journal-title":"BMC Med Educ"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"304","DOI":"10.22454\/FamMed.2023.750371","article-title":"Optimizing survey response rates in graduate medical education research studies","volume":"55","author":"Ericson","year":"2023","journal-title":"Fam Med"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"241","DOI":"10.3102\/0013189X20912798","article-title":"Interpreting effect sizes of education interventions","volume":"49","author":"Kraft","year":"2020","journal-title":"Educ Res"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"947","DOI":"10.3109\/01421591003686229","article-title":"Measuring the educational environment in health professions studies: a systematic review","volume":"32","author":"Soemantri","year":"2010","journal-title":"Med Teach"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1870311\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T11:10:27Z","timestamp":1785496227000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1870311\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,31]]},"references-count":40,"alternative-id":["10.3389\/fmed.2026.1870311"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1870311","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,31]]},"article-number":"1870311"}}