Abstract
BACKGROUND: Health systems science (HSS) education is an increasingly important component of undergraduate medical education. Despite curricular advances, the ways in which clinicians implement health systems science knowledge in everyday clinical practice, health systems thinking, remains understudied. A better understanding of how clinicians engage in health systems thinking to address everyday problems in clinical contexts is needed. METHODS: We conducted semi-structured interviews with 10 expert clinicians experienced in undergraduate medical education, health systems science, and curriculum development to identify components of competent health systems thinking. Interview questions were informed by ecological systems theory and literature on learning professional competencies. RESULTS: Through interviews with experts, we have come to define health systems thinking (HST) as “an approach to solving problems in healthcare systems that utilizes a deeper understanding of interconnections and behavior of the entire system. As a skill, it coordinates the application of clinical and HSS knowledge and skills toward solving a contextual problem in the healthcare environment.” Clinician comments support the idea that HST is a metacognitive process rather than a specific subset of knowledge domains or affective attributes. This process requires that clinicians understand and navigate pressures on patient care originating from surrounding meso- and macro-systems. CONCLUSIONS: Medical students require more explicit exposure to HSS knowledge being implemented in clinical environments, and varied examples highlighting how meso- and macro-system patterns can impact individual patient care. This metacognitive integration of HSS knowledge into everyday clinical practice is critical for preparing medical students to meet the requirements of the accreditation council for graduate medical education (ACGME) core competencies in residency programs. Health systems thinking requires a method of operational assessment to provide students feedback and highlight targeted interventions for further development. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12909-026-08653-6.