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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Med Educ . 2026 Mar 5;26:593. doi: 10.1186/s12909-026-08885-6 Search in PMC Search in PubMed View in NLM Catalog Add to search The effectiveness of the “Early clinical exposure” course based on narrative medicine in cultivating the professional qualities of undergraduates in clinical medicine: a mixed-methods study Zhao Li Zhao Li 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China Find articles by Zhao Li 1, # , Huijuan Cai Huijuan Cai 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China Find articles by Huijuan Cai 1, # , Xiaolin Yang Xiaolin Yang 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China 2 Southern Medical University, Guangzhou, 510515 Guangdong P. R. China Find articles by Xiaolin Yang 1, 2 , Jingsong Lin Jingsong Lin 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China Find articles by Jingsong Lin 1 , Wenhua Cao Wenhua Cao 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China Find articles by Wenhua Cao 1 , Peng Zhang Peng Zhang 3 Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515 P. R. China Find articles by Peng Zhang 3 , Jing Ren Jing Ren 4 The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510282 P. R. China Find articles by Jing Ren 4 , Dayong Zheng Dayong Zheng 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China Find articles by Dayong Zheng 1, ✉ Author information Article notes Copyright and License information 1 The Eighth Affiliated Hospital, Southern Medical University (The First People’s Hospital of Shunde), Foshan, 528000 Guangdong P. R. China 2 Southern Medical University, Guangzhou, 510515 Guangdong P. R. China 3 Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515 P. R. China 4 The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510282 P. R. China ✉ Corresponding author. # Contributed equally. Received 2025 Sep 27; Accepted 2026 Feb 19; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13069781 PMID: 41787452 Abstract Background Global medical education frameworks (WFME, ACGME) stress integrating early clinical exposure (ECE) and humanistic cultivation, but traditional ECE (including some Chinese models) prioritizes procedural familiarity over empathy/doctor‒patient communication, failing the biopsychosocial model. Narrative medicine (NM) fosters empathy but is rarely integrated into undergraduate ECE. In alignment with 2022 China Undergraduate Medical Education Standards, this study tests an NM-integrated “Early Clinical Practice” course for clinical undergraduates. Methods The mixed-methods study included 600 clinical undergraduates from the 2023 Southern Medical University. A 32-hour mandatory course (8 h theory: career planning, healthcare systems, NM; 24 h practice: hospital visits, holiday practice) was implemented. The data were obtained from prescourse (520 valid) and postcourse (546 valid) surveys, clinical skill assessments, and 582 reflective reports and were analyzed via SPSS 26.0 and thematic analysis. Results Following the course, 84.25% participants reported an increase in professional enthusiasm, 82.23% had gained preliminary clinical reasoning. Additionally, 71.79% had enhanced humanistic awareness, and 69.23% had applied NM techniques.The mean score for clinical skills was notably high (empathy: 85.60 ± 5.98). Over 90% of the reflective reports noted career/humanistic gains. Conclusions The NM-integrated course effectively boosts undergraduates’ professional identity, clinical reasoning, and humanistic literacy. Future optimization of NM practices and holiday arrangements is needed based on Kirkpatrick’s evaluation model. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-026-08885-6. Keywords: Early Clinical exposure, Narrative Medicine (NM), Clinical Medical Education, Medical Professionalism, Undergraduate Medical Students, Clinical Reasoning Background Globally, modern medical education reform has centered on overcoming the limitations of traditional knowledge-focused curricula, with authoritative frameworks explicitly emphasizing the integration of early clinical exposure(ECE) and humanistic cultivation. For example, the World Federation for Medical Education (WFME) has listed “early clinical engagement” as a core requirement in its global basic medical education standards, urging medical schools worldwide to connect preclinical learning with clinical practice in the early stages of undergraduate training [ 1 ]. Similarly, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has incorporated “professionalism” and “interpersonal communication skills” into its core competency system, reflecting a global consensus on moving beyond pure technical skill training to develop patient-centered, humanistic medical professionals [ 2 ]. ECE defined as authentic interactions with clinical settings, patients, or healthcare teams during preclinical education, has become a widely adopted practice across international medical curricula to enhance students’ professional identity and clinical relevance. European medical schools have implemented ECE through community-based placements and supervised patient encounters, with studies confirming improved student engagement and understanding of clinical workflows [ 3 ]. In Asia, institutions in Japan and Singapore have also introduced ECE programs, although most evaluations focus solely on clinical skill acquisition rather than the development of humanistic qualities [ 4 ]. However, a universal challenge persists: traditional ECE models—either in international contexts or some Chinese programs—tend to adopt a one-way “hospital visit + process explanation” approach. This model prioritizes familiarity with clinical procedures but neglects the systematic cultivation of students’ empathy, doctor‒patient communication skills, and ethical reasoning, ultimately failing to meet the demands of the modern biopsychosocial medical model advocated by the World Health Organization (WHO) [ 5 ]. Narrative medicine (NM), pioneered by Charon R., guides learners to listen to, interpret, and honor patients’ disease narratives, thereby fostering empathy and narrative thinking—capabilities identified as essential for addressing patients’ psychological and social needs by global medical education bodies [ 6 ]. As a core component of medical humanities, NM has been applied in medical curricula across North America, Europe, and Australia [ 7 ]. As noted in existing research on ECE effectiveness including studies on Chinese medical education, and there is a clear gap in the exploration of how humanities-integrated design can enhance ECE outcomes, and NM-related research rarely links theoretical teaching to early clinical exposure scenarios [ 8 ]. In line with global educational trends, China’s 2022 version of the China Undergraduate Medical Education Standards - Clinical Medicine Major explicitly mandates “early clinical, frequent clinical, repeated clinical” teaching philosophy and identifies humanistic literacy as a core training objective [ 9 ]. However, Chinese ECE programs still face the same challenge as their international counterparts: balancing clinical exposure with humanities cultivation. To address this gap, this study draws on both global ECE best practices and localized educational requirements to design an “Early Clinical Practice” course that systematically integrates NM into undergraduate ECE. By evaluating the course’s impact on clinical medicine undergraduates’ professional cognition, clinical thinking, and humanistic qualities, this research aims to provide empirical support for ECE teaching reform—offering a replicable model that aligns with global medical education goals while addressing the unmet need for humanities-integrated early clinical training in the Chinese context. Methods The aim of this study was to explore the effectiveness of the ECE course integrated with the NM in cultivating the professional cognition, clinical reasoning, and humanistic qualities of clinical medicine undergraduates.We used a mixed-methods study combining quantitative research (precourse and postcourse surveys, clinical skill simulation assessments) and qualitative research (analysis of student reflective reports, in-depth interviews with teachers and students). Setting The study was conducted at Southern Medical University and its affiliated hospitals (The Eighth Affiliated Hospital, Nanfang Hospital, Zhujiang Hospital) from September 2023 to June 2024. The ECE course was carried out in Eighth Affiliated hospitals, covering departments such as emergency departments, narrative sharing centers, health management centers, and medical research centers. Characteristics of the participants The research subjects were 600 undergraduate students of the 2023 clinical medicine major at Southern Medical University, including 3 classes (300 students) at the First Clinical Medical College (Nanfang Hospital) and 3 classes (300 students) at the Second Clinical Medical College (Zhujiang Hospital). The inclusion criteria were as follows: students who completed all course links (theoretical teaching + practical teaching), participated in precourse and postcourse surveys, and submitted valid reflective reports (word count ≥ 500 words, with practical experience and personal insights). The exclusion criteria were as follows: students who did not fully participate in the course, had missing survey data, or whose reflective reports were unqualified (insufficient word count, empty content). Finally, 582 students’ reflective reports were included in the analysis, with an effective rate of 97.00%. The sample size was determined on the basis of the principle of “10–15 samples per variable” in quantitative research, and the number of research variables (such as professional enthusiasm, career awareness, and clinical thinking) was approximately 40, so a sample size of 600 was considered sufficient. Curriculum design and implementation This mandatory course was meticulously crafted in alignment with Kern’s six-step curriculum design framework (needs assessment, goal setting, content selection, teaching method design, implementation, and evaluation) and is integrated within the undergraduate clinical medicine program’s ECE curriculum system. Spanning three consecutive semesters, from the latter half of the first academic year to the latter half of the second, the course comprises 32 credit hours and awards 1 academic credit. As depicted in Fig. 1 , the curriculum’s inception involved a comprehensive two-tier needs assessment to discern the primary requirements of junior students regarding early clinical exposure. Subsequently, multifaceted course objectives were set, encapsulating knowledge, skills, and attitudes. The content curation emphasized a balance between “light theory” and “immersive practice,” seamlessly blending 8 h of theoretical modules with 24 h of hands-on practice. Pedagogy was diversified, incorporating case-based lectures, small-group observations, and a hybrid of online and offline practices. The hospital’s Science and Education Department spearheaded the implementation, ensuring appropriate credit hour distribution and module coherence. The evaluative mechanism incorporated both formative (80%) and summative (20%) assessments, with results denoted as pass/fail. Fig. 1. Open in a new tab Curriculum design framework of the early clinical exposure course based on Kern’s six-step approach The detailed design of each theoretical and practical teaching module is presented in Table 1 below. Table 1. Details of theoretical and practical teaching modules in curriculum design and implementation Teaching Type Total Hours Module Name Core Teaching Content Teaching Method Teaching Effect / Requirements Theoretical Teaching (8 h) 2 h Subject Classification and Career Planning 1. Hierarchical structure of medical academic training (undergraduate, postgraduate, doctoral stages) 2. Core professional competencies for clinicians (clinical skills, interpersonal communication, humanistic literacy, etc.) Case-driven + interactive guidance (Taught by senior clinical teachers with more than 10 years of clinical and teaching experience) 78% of students could clearly identify 1–2 target specialist directions and raise in-depth questions about postgraduate training pathways, with a significant improvement in their career planning awareness. 2 h Healthcare Systems and Hospital Operations 1. China’s healthcare service system 2. Organizational structure of general hospitals (administrative, clinical, medical technology departments) 3. Core hospital management systems (medical quality control, patient privacy protection, etc.) Onsite mapping + scenario simulation (Taught by a team of hospital administrators and clinical department directors) More than 90% of students could accurately describe the cross-departmental collaborative workflow of clinical services, realizing a cognitive shift from “memorizing department functions” to “understanding system operation logic”. 4 h Narrative Medicine Guided by the theoretical system of Chinese narrative medicine and medical professionalism, the integration of typical clinical cases (tumor diagnosis and treatment narratives, medical dispute mediation cases, etc.) to teach the integrated application of narrative thinking and evidence-based thinking Storytelling + role-playing (Taught by professional narrative medicine teachers) More than 60% of students could combine “empathy expression + medical information delivery” in doctor-patient communication simulation, and initially master the core clinical communication skills of narrative medicine. Practical Teaching (24 h) 20 h Hospital Visits Acting as teachers’ observational assistants to conduct systematic visits to key clinical and medical technology departments of the hospital, connecting basic medical knowledge with clinical practice, and perceiving the connotation of clinical workflow and humanistic care Group onsite visits + daily note feedback 1. Students completed real clinical observations without preset cases 2. Onsite observation notes were required to be submitted and checked with daily comments and guidance by instructors 3. Each visit to key departments lasted 2–3 h. (Groups of 5–6 students, led by clinical instructors with more than 5 years of clinical experience who received unified pre-training) 4 h Holiday Practice Carrying out three types of practical activities: outpatient guidance, ward nursing volunteering, and community health education volunteering; the core was to apply narrative medicine communication skills and humanistic care concepts to practical medical service scenarios Blended online + offline practice (Dedicated instructors assigned by scenario: clinical nurses / community health workers) 1. 90% of students voluntarily participated in offline practice, and 10% of students restricted by geographical factors completed the alternative task of making medical science popularization videos, ensuring the feasibility of practice 2. After practice, students were required to submit a practice report including practical experience and cognitive insights, as well as a parallel medical record integrating objective medical data and patients’ subjective illness experience 3. Instructors graded the submissions based on the depth of reflection and the application of narrative medicine skills, and organized a post-practice sharing meeting to promote peer learning and experience exchange. Open in a new tab Research Tools Survey Questionnaire and Implementation A self-designed structured questionnaire was used, which included pre-course and post-course versions. Both instruments were developed based on the objectives of a narrative medicine-based early clinical experience course, relevant validated scales [ 11 ], and expert consultation (three medical education specialists and two narrative medicine experts). The pre-course survey, distributed one week before the course began, consisted of eight items examining students’ motivation for choosing medicine, professional enthusiasm, perceived learning difficulty, career intentions, and willingness to pursue further education [ 12 ]. A total of 520 valid responses were collected (effective rate: 86.67%). The post-course survey, administered one week after the course ended, comprised 18 items evaluating curriculum effectiveness, application of narrative medicine, changes in career planning, and suggestions for improvement [ 13 ]. A total of 546 valid responses were obtained (effective rate: 91.00%).Detailed information on the questionnaire structure and item distribution is presented in Table 2 . Table 2. Pre- and post-course survey design Survey Timing Focus Areas Items Valid Responses (Rate) Pre-course 1 week before Major choice motivations, professional enthusiasm, learning difficulty perception, career intentions, further education willingness 8 520 (86.67%) Post-course 1 week after Curriculum effectiveness, NM application, career planning changes, improvement suggestions 18 546 (91.00%) Open in a new tab Student Learning Materials (Reflective Reports) According to the course requirements, students need to submit a reflective report of no less than 500 words, including practical experiences (details of hospital visits and holiday practice), changes in career perception (before and after the course), insights into humanistic literacy (understanding doctor‒patient communication, empathy, etc.), and the application of NMs (specific cases of applying NMs in practice), and attach at least 2 pictures related to the practice. The research team formulated a unified coding standard and coded the report content in five dimensions: “career cognition”, “clinical reasoning”, “humanistic literacy”, “NM application”, and “course suggestions”. Data collection and analysis Data collection The quantitative data were collected through an online questionnaire platform (Questionnaire Star), and the data were cleaned with Excel 2021 (to eliminate questionnaires with missing key information or obvious logical errors). Qualitative data: Collected through the course management system (students upload reflective reports online), the research team checked the completeness of the reports (word count, pictures, content integrity) before analysis. Data analysis For quantitative analysis, SPSS 26.0 software was used for descriptive statistical analysis. Count data (such as the proportion of students with improved professional enthusiasm) were expressed as n (%), and measurement data (such as clinical skill simulation assessment scores) were expressed as x ± s. The thematic classification results and representative quotations of reflective reports were sorted out, and the interrater reliability exceeded 0.8.The thematic analysis method was used. First, two researchers independently read the reflective reports to familiarize themselves with the data; then, they extracted initial codes (such as “realizing the responsibility of doctors” and “learning to communicate with patients in plain language”); next, they merged similar codes into subthemes (such as “career cognition improvement” and “communication skill enhancement”); and finally, they summarized the subthemes into core themes (such as “the course promotes the improvement of students’ professional quality”). When there was a disagreement in coding, a third researcher participated in the discussion to reach a consensus, ensuring that the interrater reliability exceeded 0.8. Results Basic situation of the research subjects In the postcourse survey, the distribution of student classes was as follows: 106 students (19.41%) in Class 1 of Grade 1, 90 students (16.48%) in Class 2 of Grade 1, 107 students (19.60%) in Class 3 of Grade 1, 66 students (12.09%) in Class 1 of Grade 2, 80 students (14.65%) in Class 2 of Grade 2, and 97 students (17.77%) in Class 3 of Grade 2. There were 320 males (58.61%) and 226 females (41.39%), which was roughly consistent with the gender ratio of clinical medicine majors. Among the 582 reflective reports included in the analysis, 538 (92.44%) met the word count requirement and had substantial content, and 44 (7.56%) had insufficient word counts but contained extractable valid information. Precourse baseline cognition of students Major choice motivation A total of 249 students (47.88%) chose clinical medicine because of “strong interest in medicine”, 157 students (30.19%) were influenced by “family or friends’ recommendations”, 81 students (15.58%) considered “social status and income”, and 33 students (6.35%) had other reasons (such as “wanting to help others”). Professional enthusiasm A total of 303 students (58.27%) had “above average” enthusiasm for their major, 130 students (25.00%) had “average” enthusiasm, 71 students (13.65%) had “very high” enthusiasm, and only 16 students (3.08%) had “below average” or “very low” enthusiasm. Career orientation and willingness to pursue further education Before the course, 62.11% of the students tended to be “clinical frontline doctors”, 28.46% considered “medical research”, and the rest chose other directions (such as medical education and medical administration). With respect to the willingness to pursue further education, 59.23% of the students desired to pursue further education, 22.31% were undecided, and 18.46% had no intention to pursue further education. Course effectiveness evaluation results To minimize bias, all postcourse surveys were conducted after the release of course grades, and the evaluation results were not linked to academic performance . Changes in professional enthusiasm and career perception After the course, 27.66% of the students had “significantly improved” professional enthusiasm, 56.59% had “somewhat improved”, and only 2.19% (11 students with “somewhat decreased” enthusiasm and 1 student with “significantly decreased”) had decreased enthusiasm. The impact of each course module on students’ career awareness is shown in Table 3 . “Healthcare systems and hospital operations” and “hospital visit practices” had the highest impact proportions (67.77% and 67.03%, respectively), followed by “subject classification and career planning” (57.14%), “NM theory and practice” accounted for 40.29%, and “holiday practice activities” had the lowest impact proportion (15.20%). Table 3. Impact of course modules on career cognition ( n = 546) Course Module Number of Choices Proportion (%) Healthcare systems and hospital operations 370 67.77 Hospital visit practice 366 67.03 Subject classification and career planning 312 57.14 Narrative Medicine theory and practice 220 40.29 Holiday practice activities 83 15.20 Other 1 0.18 Total (multiple choices allowed) 1352 - Open in a new tab The sample size was 546. Since some students selected multiple options , the total number of choices was greater than 546 In the reflective reports, 93.13% of the students (542 reports) mentioned positive changes in career perception. For example, one student wrote, “Witnessing the emergency rescue process in the emergency department and the communication between doctors and the families of brain-dead patients in neurosurgery, I deeply realized that the medical profession is not only about mastering professional technology but also about shouldering the responsibility of saving lives and accompanying patients through difficult times.” Another student mentioned, “The visit to the health management center made me understand that medicine is not only about treating diseases but also about preventing diseases. It is also a kind of medical responsibility to help the subhealthy population build a health defense line.” Cultivation effects of clinical thinking and abilities A total of 82.23% of the students believed that the course helped establish preliminary clinical reasoning, 27.47% of whom thought it was “very helpful”, and 54.76% thought it was “somewhat helpful”. The effects of the course on enhancing students’ various levels of awareness and ability are shown in Table 4 . “Humanistic care awareness” had the highest enhancement proportion (71.79%), followed by “doctor‒patient communication skills” (68.86%), “clinical reasoningability” (60.07%), “professional responsibility” (54.03%), and “team collaboration ability” (53.85%), while only 2.93% of the students thought that there was no significant change. Table 4. Effect of the course on enhancing students’ awareness and ability ( n = 546) Awareness/Ability Dimension Number of Choices Proportion (%) Humanistic care awareness 392 71.79 Doctor‒patient communication skills 376 68.86 Clinical reasoning ability 328 60.07 Professional responsibility 295 54.03 Team collaboration ability 294 53.85 No significant change 16 2.93 Total 1379 - Open in a new tab The sample size was 546. Since some students selected multiple options , the total number of choices was greater than 546 In the reflective reports, 65.29% of the students (380 reports) recorded the process of establishing clinical reasoning. For example, one student wrote after the internship in the Department of Respiratory and Critical Medicine: “In the morning case discussion, the attending doctor analyzed the patient’s condition from multiple angles such as symptoms, medical history, and examination indicators, and formulated a personalized treatment plan. This made me realize that clinical thinking is not the mechanical application of textbook knowledge but rather the comprehensive analysis and judgment on the basis of the actual situation of patients.” Another student mentioned, “When observing laparoscopic surgery, the chief surgeon predicted the possible variation of the bile duct in advance and made corresponding preparations. This let me know that clinical thinking also includes the prediction and response to potential risks.” In addition, phrases such as “the importance of aseptic operation”, “the rigor of medical record writing”, and “the necessity of multidepartment collaboration” appeared many times in the reports, which further confirmed the effectiveness of the course in cultivating clinical ability. Recognition of practical links and assessment methods A total of 86.26% of the students believed that practical links (hospital visits, holiday practices) were “very helpful” (32.05%) or “relatively helpful” (54.21%); 87.54% of the students recognized the assessment method of “formative assessment (80%) + summative assessment (20%)”, of which 33.88% thought it was “very reasonable” and 53.66% thought it was “relatively reasonable”, and only 2.57% (12 students thought it was “not very reasonable” and 2 students thought it was “very unreasonable”) thought it needed adjustment. In the reflective reports, 88.66% of the students (516 reports) gave positive evaluations of practical links. For instance, one student commented: “Assisting elderly patients in operating self-service machines made me realize the importance of adapting to patients’ communication needs.” Another student noted: “Obstetric ward rounds demonstrated the fulfillment of professional responsibilities toward life through multidisciplinary collaboration.” Regarding assessment methods, a student suggested: “Writing reflective reports helps consolidate learning outcomes; incorporating periodic logs in future implementations could facilitate timely summarization.“Thematic classification and representative quotations are presented in Table 5 . Table 5. Thematic classification and representative quotations of reflective reports ( n = 582) Core Theme Subtheme Representative Student Quotations Proportion (%) Career Cognition Improvement Witnessing emergency rescue and communication with families of brain-dead patients, I deeply realized that medicine is not only about technology but also about the responsibility of saving lives and accompanying patients through difficult times. 93.13 Clinical Reasoning Establishment Clinical Reasoning Establishment The attending doctor analyzed the patient’s condition from multiple perspectives such as symptoms, medical history and examination indicators, which made me understand that clinical reasoning is not the mechanical application of textbook knowledge.|65.29| |Humanistic Literacy Enhancement|Doctor-Patient Communication Ability|Using the metaphor of weeds in the garden to explain tumor growth and then the treatment plan, the patient’s anxiety was significantly relieved—this is the power of narrative medicine. 71.79 Narrative Medicine Application Narrative Skill Practice Listening to a diabetic patient’s struggle with diet control made me realize that doctors need to deliver medical information in plain language. 62.37 Course Suggestion NM Practical Improvement I hope to increase NM workshops and set up simulated doctor-patient communication scenarios to practice the application of narrative medicine in real situations. 58.08 Open in a new tab Special assessment results of the narrative medicine Comprehension and application ability A total of 69.23% of the students could master the application of NM, of which 19.60% were “proficient in application” and 49.63% “understood and partially applied”; 25.27% “understood the basic concepts but had difficulty applying”; and only 5.49% (29 students “only understood the concept” and 1 student “still did not understand”). A total of 85.35% of the students believed that NM was “very helpful” (28.94%) or “relatively helpful” (56.41%) for understanding doctor–patient relationships. In the reflective reports, 62.37% of the students (363 reports) recorded specific cases of applying NM in practice. For example, one student wrote, “When the teaching doctor explained the condition to a cancer patient, he first handed the patient a glass of warm water to ease the patient’s tension and then used the metaphor of ‘weeds in the garden’ to explain the growth of tumors. This ‘empathy - explanation - confirmation’ communication method is exactly what we learned in the NM class.” Another student mentioned, “In the gastroenterology department, I tried to explain the meaning of ‘elevated creatinine’ to the patient in plain language, from the function of the kidneys to the possible reasons for the increase. The patient’s expression changed from anxiety to understanding, which made me realize that NMs can build a trust bridge between doctors and patients.” In addition, one student reflected: “Facing critically ill patients, I once did not know how to comfort them. Through learning NM, I understand that listening carefully to patients’ concerns and accompanying them silently is also a kind of treatment.” Future application intentions and improvement needs A total of 87.91% of the students would “certainly” (31.87%) or “probably” (56.04%) apply NM in future studies and work; 43.22% of the students thought that NM education should strengthen “practical application”, 31.50% suggested increasing “case analysis”, and 20.70% hoped to deepen “theoretical depth”. In the reflective reports, 58.08% of the students (338 reports) proposed suggestions for NM teaching. For example, one student suggested, “I hope to increase NM workshops, set up simulated doctor‒patient communication scenarios, and let us practice the application of NM in real situations.” Another student mentioned, “Writing parallel medical records can help me record patients’ disease stories and personal feelings. It is suggested to increase such practical tasks in the course to improve the ability to apply NM.” Changes in career planning Career intention After the course, 88.28% of the students tended to engage in “clinical frontline work” after graduation, 40.66% considered “medical research” (some students chose both clinical work and research), 30.77% focused on “medical education”, and only 6.41% indicated “not engaging in medical-related work”. Willingness to Pursue Further Education. A total of 75.09% of the students had an increased willingness to pursue further education, 31.32% “significantly increased” and 43.77% “somewhat increased”; 22.53% had “no change”; and only 2.38% (11 students “somewhat decreased” and 2 students “significantly decreased”) had a decreased willingness. Adjustment of career planning A total of 58.79% of the students had “tentative changes” in their career planning (such as clarifying the direction of specialized disciplines), 36.63% “maintained the original plan”, and only 4.21% “became more uncertain”. In the reflective reports, 72.16% of the students (419 reports) mentioned adjustments in career planning. For example, one student wrote after the internship in the Department of Cardiovascular Medicine: “Seeing doctors race against time to rescue patients with myocardial infarction, I made up my mind to engage in cardiovascular clinical work in the future. I also realized that I need to improve my professional level through postgraduate study to better cope with complex clinical situations.” Another student mentioned, “The health education activities in the obstetrics maternity school made me interested in medical education. I hope to engage in clinical work while carrying out medical popularization and education work to spread medical knowledge to more people.” Discussion Integrating narrative medicine into early clinical exposure: addressing practical needs of medical education reform The central challenge in global medical education reform today involves resolving the dual issues of disconnection between basic science and clinical practice, as well as fragmentation between humanistic training and skill development within traditional early clinical exposure (ECE) programs [ 13 ]. Authoritative frameworks such as those from WFME and ACGME, along with the 2022 edition of “Chinese Undergraduate Medical Education Standards,” explicitly require deep integration of humanities literacy cultivation with early clinical practice to align with core competency requirements for clinicians under the biopsychosocial medical model [ 14 ]. However, current practices often confine humanities education to standalone courses or postgraduate levels. As an effective approach for cultivating empathy and doctor-patient communication skills [ 15 ], narrative medicine has yet to systematically integrate with ECE at lower undergraduate levels. Traditional ECE curricula typically emphasize procedural knowledge and technical skill training, creating critical bottlenecks that hinder quality improvement in early medical education. Against this background, systematically incorporating narrative medicine into ECE curricula represents a targeted response to core demands of medical education reform [ 16 ]. By breaking down barriers of theoretical isolation in humanities education, this integration enables simultaneous advancement of humanities literacy development and clinical cognitive practice. It transforms ECE from “pure clinical process recognition” toward comprehensive cultivation of “cognition + capability + literacy,” aligning with contemporary trends emphasizing equal importance of humanities and clinical practice in medical education [ 17 ], while providing practical solutions for existing challenges in early clinical education. Core significance of curriculum implementation outcomes: validating scientific rigor and practical value of the integrated model This study’s narrative medicine-integrated ECE curriculum, designed based on Kerns’ curriculum principles, achieved significant educational outcomes. These results not only demonstrate the curriculum’s practical value but also reveal core significance at theoretical and talent development levels. From the humanities cultivation dimension, 69.23% of students mastered fundamental narrative medicine application skills, while 62.37% could document narrative communication cases in clinical practice. This confirms the integrated model effectively translates abstract humanities theories into actionable clinical communication capabilities for junior medical students, validating “clinical contextualization” as a key pathway for implementing humanities education [ 16 ]. Savitha et al. similarly noted that practical narrative medicine teaching (e.g., having students write patient illness narratives) significantly enhances application abilities [ 17 ], corroborating our findings. From cognitive and competency dimensions, the curriculum’s “medical system theory + hospital observation practice” model allowed students to directly experience both the urgency of emergency rescue scenarios and the transmission of patient stories through narrative sharing. This “theory-situation-experience” closed-loop design effectively bridges basic medical knowledge with clinical practice, enhancing professional immersion and identity formation. The impact of healthcare system and hospital operation modules corresponds with cognitive characteristics during the industry awareness initiation phase for junior medical students, substantiating the scientific validity of the curriculum’s progressive design sequence (“cognition first, then capability, finally literacy”). From career development dimensions, students demonstrated increased enthusiasm for professional learning, clearer preferences for frontline clinical work, stronger intentions for advanced studies, and positive shifts in career cognition. These outcomes indicate the curriculum successfully integrated clinical practice with career planning, establishing preliminary professional identity during early undergraduate stages and laying foundational groundwork for subsequent medical training and career development. Overall, this study confirms that the integrated model of narrative medicine and ECE aligns with cognitive development patterns of junior medical students while meeting early medical education objectives. Its established “theory-practice-reflection” triad teaching system extends ECE’s educational value beyond bridging basic and clinical domains to encompass literacy cultivation and career guidance, thereby enriching the connotation and boundaries of early clinical education. Relationship between this study and previous research: alignment with classical conclusions and localized extension and deepening Our findings strongly align with classical research conclusions in ECE and medical humanities education fields, while achieving localized extension and theoretical deepening through integration with China’s medical education realities, thus supplementing and refining existing scholarship. Consistent with Simmenroth et al.‘s conclusion that “ECE effectively enhances medical student professional identity,” our curriculum’s “theory-situation-experience” closed-loop design enhanced professional immerion and identity formation, corroborating their findings on early clinical experiences strengthening professional identification [ 16 ]. However, this study further incorporates narrative medicine modules and constructs a systematic progressive curriculum system, transcending limitations of purely emphasizing clinical environment exposure and professional attitude formation [ 17 ]. Aligning with Yang Xiaolin et al.‘s [ 10 ] conclusion that “narrative medicine effectively cultivates medical student empathy and narrative thinking,” this study breaks traditional application scenarios [ 15 ] by deeply integrating narrative medicine with junior-year ECE, validating its applicability in early clinical education and enriching theoretical connotations of “contextualized narrative medicine application.” Resonating with Dijk et al.‘s [ 18 ] proposition that “incorporating patient perspectives into early medical education enhances student-centered care awareness,” this study operationalizes patient perspectives in early clinical cognition among junior medical students through narrative medicine implementation, providing new empirical evidence for this theoretical assertion. Furthermore, this study represents the first systematic integration of NM into undergraduate early-year ECE within China’s medical education system. A localized integrated teaching model was developed to align with Chinese medical education standards and the characteristics of medical students. From a localization perspective, this research validated the universality of Kerns’ curriculum design principles in medical education course development. It also provides replicable practical paradigms for developing countries to explore humanities-clinical integrated ECE within the global medical education context, achieving an advancement from classic theoretical adoption to localized innovative practice. Research advantages and limitations Advantages Large sample size and high-quality data ensure result reliability This study enrolled 600 undergraduates from two clinical medical colleges of Southern Medical University, covering students of different grades and genders. The sample size meets the principle of “10–15 samples per variable” for quantitative research (involving approximately 40 variables such as professional enthusiasm and clinical thinking). Eventually, 582 reflective reports were included in the analysis (with an effective rate of 97.00%), and 92.44% of these reports met the requirements of “≥500 words, including practical experiences and personal insights”. This large sample size effectively reduces random errors, while high-quality primary data records the authentic experiences and cognitive changes of students, providing sufficient empirical support for the conclusions and significantly enhancing the representativeness and reliability of the results. Mixed research methods avoid limitations of single methods The study innovatively adopted a “quantitative + qualitative” mixed research method, which effectively compensates for the inherent defects of single research methods. This design aligns with the application advocacy of mixed methods in medical education research, where purely quantitative assessment is prone to “reductionism tendencies”, while purely qualitative research has limitations in generalizability. In the quantitative dimension, pre-course and post-course comparative questionnaires (with effective recovery rates of 86.67%–91.00%) and clinical skill simulation assessments were used to systematically quantify changes in indicators such as students’ professional enthusiasm and clinical thinking, with the empathy ability score reaching 85.60 ± 5.98, providing objective quantitative evidence for course effectiveness. In the qualitative dimension, thematic analysis was applied to code the reflective reports (with inter-rater reliability > 0.8), revealing in-depth cognitive changes such as the shift from “disease-centered cognition to person-centered care concept”. This combination of “quantitative data verifying effect magnitude + qualitative data revealing internal mechanisms” forms a complete evidence chain, perfectly aligning with the core value of mixed methods in “balancing quantitative focus and retaining assessment authenticity”, and avoiding the one-sidedness of single research methods. Innovative course design fills gaps in medical humanities education This study is the first to systematically integrate narrative medicine into ECE course for undergraduate clinical medicine students, constructing a “theory-practice-reflection” trinity system. This design is not only in line with the requirements of “ECE and multiple clinical practices” in the National Standards for Undergraduate Medical Education Quality - Clinical Medicine Program (2022 Edition), but also directly responds to the value of integrating patient perspectives into early medical education. As confirmed by Dijk ‘s systematic review [ 18 ], integrating patient perspectives into early medical education can significantly improve students’ patient-centered awareness and communication skills. This study further transforms this concept into operable course practices through modules such as “narrative sharing center visits and parallel medical record writing”. The data showed that 69.23% of students could apply narrative medicine, and 62.37% recorded application cases, effectively addressing the pain point of “disconnection between humanities education and clinical practice” in traditional medical education, and providing a replicable new path for the in-depth integration of medical humanities education and clinical practice. Limitations Subjectivity in data and lack of objective validation The current study was primarily dependent on self-reported data, such as surveys and reflective reports, which are susceptible to social desirability bias. For instance, participants might overstate their perceived improvements to align with anticipated expectations. Although thematic analysis of reflective reports provides valuable insights, it is inherently subject to researchers’ subjective interpretations, despite measures like interrater reliability. The absence of objective complementary data, such as standardized patient (SP) evaluations of communication skills or blinded clinician grading of case analyses, to corroborate self-reported outcomes, diminishes the validity of assertions regarding clinical thinking or NM application. It is also important to note that students’ post-course responses were likely influenced by the course’s NM discourse. Although triangulation, thematic diversity (Table 3 ), and evidence of skill transfer (62.37% documented use of NM) suggest authentic learning beyond mimicry, educational outcomes cannot be fully disentangled from the discursive framework in which they are acquired. Limited generalizability to diverse contexts The findings of this study are limited to the context of Southern Medical University and the China’s Undergraduate Medical Education Standards (2022), which have significant differences from the accreditation frameworks used in other countries (such as the U.S. LCME, European directives). The specific model of NM implemented at this medical school (32-h, semester-based) is also different from the longitudinal patient-following model adopted by most Western medical schools, which has implications for cross-cultural transferability. Furthermore, by focusing on clinical medicine undergraduates, we did not include other health professions undergraduates (e.g., nursing, pharmacy), which further narrowed the generalisability of our findings. Directions for future research To address these limitations, future studies should adopt the following strategies:①conduct multicenter studies across diverse Chinese medical schools (top-tier, regional, vocational) with a traditional ECE control group and randomized controlled trials (RCTs), while expanding eligibility to international samples and other health professions to improve representativeness and cross-context generalizability;②Implement a 1-year and 3-year postcourse longitudinal tracking system, grounded in Kirkpatrick’s evaluation model, to measure sustained outcomes. This includes objective metrics such as OSCE scores, teacher evaluations, and patient satisfaction, alongside long-term subjective data like career choices and NM skill retention. Link this data to administrative records (e.g., transcripts, residency matches) to assess professional impact, aligning with Ismail et al.’s [ 19 ] emphasis on balancing formative and summative assessment in medical education.; ③Reduce subjectivity by supplementing self-reports with objective tools (e.g., standardized patient evaluations using validated scales like the Communication Assessment Tool, blinded clinician grading of clinical tasks) and using software (NVivo) for quantitative content analysis of reflective reports to minimize researcher bias; ④Develop adapted ECE-NM models for resource-limited settings (e.g., VR clinical simulations, online NM modules) [ 20 ], test cross-cultural applicability via international collaborations, and incorporate stakeholder perspectives (instructors, patients, educators) to evaluate feasibility and scalability. Sample representativeness and selection bias First, the participants were all from one center (Southern Medical University), which is a high-level university with good cooperation between the university and the affiliated hospitals (such as the narrative sharing centers, well-trained instructors, etc.). This may not be the case in other medical colleges or vocational schools in the region, so the research results can hardly be generalized to the overall population of Chinese medical students. Secondly, there was no control group (such as students in the traditional ECE without NM), so we could not make causal inferences about the specific effect of NM. Thirdly, the inclusion criteria (such as completing all modules and submitting valid reflective reports) led to selection bias towards active students, and the positive effects may be overestimated due to the exclusion of some less active participants. Conclusions Early clinical exposure (ECE) courses integrated with narrative medicine (NM), designed according to Kerns principles, adopt a three-dimensional design of “theory - practice - humanity”, which can effectively enhance the professional identity, clinical thinking, and humanistic literacy of clinical medicine undergraduates and clarify their career planning direction. The students’ reflective reports and other learning materials further confirmed the practical value of the course: more than 90% of the students recorded positive changes in their career awareness and humanistic literacy during the course, and more than 60% reflected on the application of clinical thinking and NM. This course conforms to the development needs of modern medical education, which is “early clinical, more humanistic”. In the future, it is necessary to further optimize the NM practical module (increase simulated communication and practical tasks) and adjust the holiday practice arrangement (adopt online and offline combinations), and conducting longitudinal tracking research based on Kirkpatrick’s evaluation model. These steps will to provide a more replicable and promotable teaching model for ECE reform in medical education. Supplementary Information Supplementary Material 1. (15KB, docx) Supplementary Material 2. (14.3KB, docx) Supplementary Material 3. (38.6MB, docx) Acknowledgements We would like to thank all the participating students for their active cooperation in completing the surveys and writing reflective reports; thank the clinical teachers of the affiliated hospitals of Southern Medical University (including The Eighth Affiliated Hospital, Nanfang Hospital, and Zhujiang Hospital, especially Pro. Li Xiaodan and Zheng Weiyang) for their support in the practical teaching of the course (such as guiding students’ hospital visits and conducting clinical skill training); and thank the staff of the online questionnaire platform (Questionnaire Star) for their technical support in data collection. Abbreviations NM Narrative Medicine ECE early clinical exposure SPSS Statistical Package for the Social Sciences Biographies Zhao Li Attending Physician, Associate Research Fellow, majoring in medical education, narrative medicine and clinical practice teaching, with research interests in the reform of ECE for medical students. Xiaolin Yang Professor, Doctoral Supervisor, majoring in narrative medicine and medical humanities education, with research interests in the integration of narrative medicine into clinical medical education. Dayong Zheng Chief Physician, majoring in clinical medicine education and teaching management, with research interests in the cultivation of the professional qualities of medical students. Authors’ contributions Li Zhao (LZ): Responsible for the design of the research plan, collection of survey data, and sorting of reflective reports.Cai Huijuan (CHJ): Participated in the implementation of the course, conducted in-depth interviews with students, and assisted in data analysis.Yang Xiaolin (YXL): Guided the design of the NM module, provided theoretical support for NM teaching, and revised the paper.Lin jingsong (LJS): Responsible for the organization of practical teaching (such as arranging hospital visits) and collected students’ practice records.Cao Wenhua (CWH): Participated in the implementation of NM teaching.Zhang Peng (ZP): Participated in the clinical skill simulation assessment, scored students’ performance, and provided professional clinical advice.Ren Jing (RJ): assisted in the coding and analysis of qualitative data (reflective reports) and identified typical cases.Zheng Dayong (ZDY): proposed the research topic, designed the overall framework of the study, guided the data analysis, wrote the first draft of the paper, and revised the final version. All the authors have read and approved the final manuscript. Funding This study was supported by the 2025 Annual Guangdong Provincial Educational Science Planning Topics (Higher Education Special Project) (No. 2025GXJK0332) and the Digital Experimental Teaching Demonstration Center for Clinical Comprehensive Competence Training of Medical Talents of Guangdong Province Education Department (No. 2024-30-8). The funder provided financial support only and did not participate in the research work. Data availability The datasets generated and/or analyzed during the current study are not publicly available due to the protection of students’ personal privacy but are available from the corresponding author (Zheng Dayong) upon reasonable request. The student reflective reports used in the study are stored in the course management system of Southern Medical University and can be provided to relevant researchers after the approval of the school’s teaching management department and the consent of the corresponding author are obtained. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of The Eighth Affiliated Hospital, Southern Medical University, and was conducted in accordance with the Declaration of Helsinki. All the participating students were informed of the research purpose, content, and risks and signed written informed consent forms. Consent for publication Not Applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Zhao Li and Huijuan Cai contributed equally to this work. References 1. 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The student reflective reports used in the study are stored in the course management system of Southern Medical University and can be provided to relevant researchers after the approval of the school’s teaching management department and the consent of the corresponding author are obtained. 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