Introduction

The Public Health and Medical Services Act, enacted in 2000, defines public healthcare as all activities conducted by the government, local authorities, and healthcare institutions to ensure universal access to medical services and to promote and protect public health, regardless of region, socioeconomic status, or field. In other words, public healthcare encompasses not only the provision of unrestricted access to medical services but also activities aimed at disease prevention and health promotion. As of December 2023, 228 public healthcare institutions [1] and 3,601 public health centers [2] have been established nationwide to provide public healthcare services in the community. However, 91 of 217 institutions (41.9%) have been unable to meet their physician staffing quotas, and the number of institutions and medical departments experiencing temporary closures has shown an annual increase. In addition, the shortage of physicians in public healthcare institutions varies significantly across communities, with communities outside metropolitan areas facing greater challenges [3].

To address the staffing challenges facing public healthcare institutions, particularly in nonmetropolitan communities, the South Korean government has begun operating a public health doctor system that requires individuals to work in medically underserved areas for 3 years as an alternative to military service. However, the number of public health doctors has decreased annually, and as of 2024, it has plummeted to half of the number recorded in 2015 [4]. Furthermore, the government has piloted the Public Health Scholarship Program since 2019, which mandates that medical graduates work in public healthcare institutions for a specified period. However, the program has faced low participation, with an average scholarship award rate of only 52% [5]. In response to the ongoing workforce shortage in public healthcare institutions, the government proposed measures under the First Comprehensive Plan for Public Healthcare in 2016 and the Second Comprehensive Plan in 2021, which included establishing universities to train healthcare professionals to work in public healthcare [6,7]. However, these plans were ultimately scrapped due to opposition from the medical community. Subsequently, as part of the Four Key Medical Reform Initiatives announced by the Ministry of Health and Welfare in 2024, the government publicized its plans to increase both the admission quotas for medical schools outside Seoul starting in 2025 and the regional talent community selection criteria for nonmetropolitan areas [8]. However, these initiatives have encountered significant challenges.

In medical schools that cultivate future healthcare professionals, community-based education (CBE) may be regarded as a strategy to address workforce shortages in public healthcare institutions and strengthen public healthcare in the community. CBE refers to learning activities aimed at implementing community-oriented education (COE) that focuses on educating communities about their health needs [9]. Recently, CBE has evolved to incorporate social accountability by fostering collaboration between communities and educational institutions, encouraging learner citizenship, and fostering a sense of social responsibility [10]. Social accountability is embedded in the definition of the “2022 Korean Doctor's Role,” which outlines physician roles and competencies [11]. The Korea Association of Medical Colleges has incorporated this concept into medical graduates' core competencies, as defined in basic medical education outcomes, with an explicit emphasis on social accountability [12].

Social accountability is a critical domain in medical education and is included in the “ASPIRE to Excellence” award category of the Association for Medical Education in Europe (AMEE), which recognizes exemplary medical schools worldwide. Rourke [13] analyzed the characteristics of 10 outstanding medical schools renowned for their achievements in social accountability and found that their curricula provided extensive exposure to CBE. Notably, the Northern Ontario School of Medicine (NOSM) University in Canada reported that as of June 2024, over half of its graduates had participated in medical activities in the Northern Ontario region [14]. This finding suggests a strong correlation between medical graduates who undergo CBE and their participation in community healthcare services. Additionally, significant differences in academic achievement [15] and career preferences [16] were observed among the students engaged in CBE. Comprehensive reviews of the educational outcomes of CBE have also been conducted [17-19]. Therefore, incorporating CBE into the medical school training of healthcare professionals is essential. This approach could be a viable strategy for cultivating human resources to staff public healthcare institutions and for addressing the persistent shortage of healthcare professionals in underserved regions.

South Korean medical schools often incorporate CBE into preventive or community medicine courses, including practical training in public healthcare institutions. However, content and implementation methods differ significantly among universities [20]. In clinical training programs, hospital-centered education remains predominant, whereas COE has been identified as the area most in need of improvement [21]. Since 2019, the Accreditation Standards of Korean Institute of Medical Education and Evaluation 2019 (ASK2019), which are based on the World Federation for Medical Education's basic medical education standards, have required medical schools to explicitly state a social accountability mission and define graduation outcomes that align with their mission [22]. Consequently, studies have analyzed case examples of social accountability practices in domestic and international medical schools [23,24], and research has been conducted on developing themes and case studies to enhance social accountability in medical education [25]. Although studies have examined practical training in primary care settings in individual medical schools [26,27], and research aimed at developing educational programs [28] has been conducted, comprehensive research on the nationwide status of CBE in South Korean medical schools remains insufficient.

The present study aimed to address this gap by investigating the status of community-based practice in South Korean medical schools and identifying the relevant needs to guide the direction of CBE in medical education. Specifically, this study examined the status of community-based practice in public healthcare institutions and analyzed opinions on the subject. The findings are expected to provide valuable information for addressing the workforce shortage faced by public healthcare institutions and for formulating educational and policy strategies to strengthen public healthcare in the community.

Methods

Ethics statement: This study was approved by the Institutional Review Board (IRB) of Gachon University Gil Medical Center (IRB No: GAIRB2023-121), and the requirement for informed consent was waived.

1. Study design and participants

We conducted a cross-sectional survey to investigate the status of community-based practice in public healthcare institutions in South Korean medical schools and to identify related needs using a sample of 40 schools. We administered an online survey from March to April 2023 using Google Forms (Google LLC, Mountain View, CA, USA). An invitation to participate in the survey was emailed to the education departments of 40 medical schools. All the participants provided informed consent before completing the survey. Of the invited schools, 32 (80.0%) participated. To ascertain the degree of homogeneity between the responding schools and the population, a statistical test was conducted to determine the difference in the ratio between the location and type of institution based on the characteristics of the medical schools. Among the 32 schools, 11 (34.4%) were in metropolitan areas and 21 (65.6%) were in nonmetropolitan areas. Regarding the type of institution, 9 (28.1%) were public and 23 (71.9%) were private schools. The proportional distribution of the responding schools relative to the population was subjected to homogeneity tests, and no significant differences were found (p>0.05), thereby indicating the representativeness of the sample.

2. Measurements

To achieve the research objectives, we developed survey questions based on prior research [19] and revised the questionnaire based on consultations with educational experts responsible for community-based practice. This study defined “community-based practice” as practical training conducted at school-designated institutions, specifically public or community-based healthcare institutions, rather than at student-selected sites. We excluded training- and lecture-based education at institutions outside this definition from the analysis.

The questionnaire requested respondents' affiliated universities and contained two main sections on the status of and opinions on community-based practice in public healthcare institutions. Items for the former were designed based on the 2023 academic year; however, for institutions where practice was suspended as of 2020 owing to coronavirus disease 2019, the responses were based on the 2019 academic year.

The survey included questions about whether individual institutions had included community-related content in their mission and graduation outcomes, and whether the school offered community-based practice courses. Respondents at medical schools offering such courses were asked to provide detailed course information such as type, year of implementation, total duration in hours, format, and the relationship between the practice institution and the medical school.

The section on opinions regarding community-based public healthcare institutional practice included multiple-choice and open-ended questions about perceptions and the structure of practical education. Regarding the former, participants were asked to use a five-point scale to rate the necessity of practice, its contribution to understanding public healthcare, and its impact on career decision-making. Regarding the latter, respondents were asked to indicate appropriate educational phases, course types, key focus areas, and obstacles to implementing practical education. Open-ended questions were included to allow respondents to opine freely.

3. Statistical analysis

We employed several data analysis methods that were appropriate for each type of survey question. Responses to multiple-choice questions were subjected to frequency analysis and the Mann-Whitney U test, whereas those to open-ended questions were analyzed using word clouds. Microsoft Office Excel 2016 (Microsoft Corp., Redmond, WA, USA) was used to organize the survey responses and perform frequency analyses. Additionally, the Mann-Whitney U test, a nonparametric statistical test suitable for identifying differences between groups with small sample sizes, was performed using IBM SPSS ver. 25.0 (IBM Corp., Armonk, NY, USA). We conducted a word frequency analysis to generate word clouds using R Statistical Software (ver. 4.3.1; R Core Team, Vienna, Austria).

Results

1. Status of community-based practice in public healthcare institutions

1) Components

The components of community-based public healthcare institutional practice are presented in Table 1. Among the surveyed medical schools, the majority, that is, 31 of 32 schools (96.9%) reported defining community-related missions and graduation outcomes, and 23 (71.9%) confirmed operating community-based practice courses at public healthcare institutions. Regarding the type of practice, the most common format involved practice lessons offered within courses, provided by 12 of 23 medical schools (52.2%), whereas the least common format entailed dedicated practical courses, provided by five schools (21.7%). Six schools (26.1%) reported offering both within-course lessons and dedicated courses.

Regarding course implementation, of the 23 medical schools that operated community-based practice courses, 20 responded to the question and three did not respond. Eighteen of the responding medical schools (90.0%) offered compulsory practical courses, whereas only two (10.0%) offered them as electives. Regarding the year in which courses were offered, the third year of medical school was the most common (17 schools, 85.0%), followed by the fourth year (11 schools, 55.0%), which coincided with the clinical clerkship period. Offering practical courses earlier in the medical curriculum was less common, with only one school (5.0%) offering the program in the first year and two (10.0%) offering it in the second year.

Regarding total practice hours, 13 schools (65.0%) provided <20 hours, whereas 10 schools (50.0%) provided ≥20 hours. Regarding practice format, the most frequent focus was public healthcare projects executed in public health-related centers, as reported by nine schools (45.0%), followed by community practice in public health centers (seven schools, 35.0%), and clinical clerkship in public hospitals (four schools, 20.0%).

2) Relationships between community-based public healthcare institutions and medical schools

We analyzed the status of the relationships between community-based public healthcare institutions and medical schools based on the responses of 19 of the 23 medical schools offering practical courses, excluding non-responding institutions (Table 2). Among the responding schools, nine (47.7%) reported operating practical courses at institutions with which they had signed a memorandum of understanding (MOU), whereas a lower proportion (13 schools, 68.4%) reported not having MOUs. Regarding the appointment of supervising physicians from practice institutions as adjunct faculty, 15 schools (78.9%) reported not appointing them, with only five schools (26.3%) indicating having made such appointments, reflecting a relatively low appointment rate.

Regarding the payment of practice institutions' practice-related expenses, all 19 schools (100%) indicated not reimbursing at least one practice institution, whereas only three (15.8%) reported reimbursement. Furthermore, three schools (15.8%) reported developing a faculty program for supervising physicians from practice institutions, whereas 16 (84.2%) reported not having such a program, highlighting a significant gap in faculty development efforts.

2. Needs assessment for community-based public healthcare institutional practice

1) Perceptions of community-based public healthcare institutional practice

The survey results regarding perceptions of community-based practice in public healthcare institutions are summarized in Table 3. We analyzed the differences in responses from 32 medical schools based on whether they provided such practices. No statistically significant difference was observed between the groups in terms of the perceived necessity of community-based practice as a component of the medical school curriculum (U=75.50, p=0.118).

Regarding the perceived contribution of community-based practice to students' understanding of and interest in public healthcare, there was no statistical difference between the groups (U=100.00, p=0.865). In addition, the difference between the groups was not statistically significant regarding the perceived contribution to public healthcare career decision-making (U=93.00, p=0.647). Overall, we identified no statistically significant differences in any of the items based on whether the medical schools implemented community-based practices.

2) Opinions on community-based public healthcare institutional practice

The survey results on needs and opinions regarding community-based public healthcare institutional practice are summarized in Table 4 and Fig. 1. Based on responses from 32 medical schools, the most appropriate means of incorporating community-based practice into the medical school curriculum was identified as a continuous process spanning the premedical and medical years, which 17 schools (53.1%) advocated. The second most appropriate implementation phase, according to 15 schools (46.9%), was during the clinical clerkship years, specifically the third and fourth years of medical school. A smaller proportion of schools (three, 9.4%) deemed the first and second years of premedical education to be suitable.

Regarding the appropriate type of community-based practice, full courses were the most frequently selected option, as indicated by 20 schools (62.5%), followed by practical lessons offered within courses (11 schools, 34.4%) and electives (7 schools, 21.9%).

Regarding key focus areas, 26 schools (81.3%) emphasized the importance of understanding and participating in public healthcare projects based on community characteristics and understanding of the public healthcare system. Other focus areas included understanding the characteristics of clinical care in public hospitals, which 12 schools (37.5%) highlighted, and exploring career paths in public healthcare, which 10 schools (31.3%) noted.

The survey also identified several obstacles in the implementation of community-based practice. The most frequently cited was the difficulty in providing faculty development for healthcare professionals at community-based practice institutions (24 schools, 75.0%). Other obstacles included the difficulty in obtaining cooperation from healthcare professionals at community-based practice institutions (21 schools, 65.6%) and the lack of compensation for healthcare professionals participating as educators (20 schools, 62.5%). Additional barriers included medical students' limited understanding of the need for community-based practice (19 schools, 59.4%) and the limited understanding of medical school faculty members (14 schools, 43.8%). Furthermore, 17 schools (53.1%) identified a lack of physical support for medical students' activities at external practice institutions as problematic and 13 schools (40.6%) reported difficulty establishing partnerships with community-based practice institutions.

The results of the word frequency analysis of 30 medical schools' open-ended responses regarding community-based public healthcare institutional practices are presented in Table 5. Words mentioned over 10 times included “practice” (56 mentions), “community” (54 mentions), “institution” (30 mentions), “student” (29 mentions), “education” (20 mentions), “faculty” (18 mentions), “university” (16 mentions), and “public” (13 mentions).

The most frequently mentioned word was “practice,” which highlighted the need for enhanced support in the areas of infrastructure development, physical resources, funding, personnel allocation, and compensation. Regarding “community,” the responses emphasized the importance of stimulating community engagement, integrating education with community initiatives, applying systematic thinking to address community challenges, and bolstering student interest and career choices through community pathways. Regarding “institution,” the responses underscored the need to improve collaboration with practice institutions, expand the number of available institutions, establish community-based practice institution networks, and implement quality evaluations of these institutions.

Related to “student,” the feedback pointed to the importance of changing student perceptions of practical education, fostering active participation and motivation, and increasing educational opportunities. Regarding “education,” the responses stressed the importance of designing curricula that reflect community responsibility, active learning strategies, and the public healthcare system. The responses related to “faculty,” like those related to “student,” mentioned the need for enhanced awareness of the importance of practical education, efforts to improve faculty involvement, greater interaction among faculty, and faculty development programs.

Regarding “university,” the comments addressed the need for increased awareness among stakeholders, a stronger commitment from university leadership, the establishment of MOUs with practice institutions, and development of networks between universities and practice institutions. Finally, regarding “public,” the responses emphasized the importance of institutional and policy support for public healthcare education, as well as the provision of practice opportunities at public healthcare institutions.

Discussion

This study analyzed the status of community-based public healthcare institutional practice in South Korean medical schools and collected related opinions. The key findings regarding the status of community-based public healthcare institutional practices were as follows. First, while 31 of the 32 surveyed medical schools included community-related content in their missions and graduation outcomes, only 23 implemented community-based practice courses at public healthcare institutions. The ASK2019 requires medical schools to explicitly define social accountability in their mission and specify graduation outcomes based on community health needs [22]. However, a 2019 study examining the missions and graduation outcomes of 40 medical schools indicated that only 23 (57.0%) had included community-related social accountability [29]. The findings of the present study show an increase to 31 schools as of 2023, suggesting that more universities have adopted ASK2019. However, these standards do not explicitly stipulate the implementation of community-based practice courses, which appear to be left to the discretion of individual medical schools.

A detailed analysis of practical education revealed that practice was most frequently offered as a course component during the clinical years (third and fourth years of medical school), with relatively low implementation during the preclinical years (first and second years of medical school). In contrast, in the United Kingdom, 29 out of 31 medical schools provide CBE starting in the first or second year, allowing students to benefit from early exposure opportunities in community settings [19]. This highlights an experiential difference wherein South Korean medical students primarily encounter limited community exposure during clinical clerkships. In South Korean medical schools, clerkships are largely hospital-centered, which has resulted in the identification of CBE as the area most in need of improvement [21]. Practical education in South Korea requires considerable attention and improvement.

Second, the proportion of schools that established MOUs with practice institutions, appointed adjunct faculty, allocated practice budgets, and developed faculty training programs was low. This indicates that many schools operate practical courses without institutional-level agreements, compensation, or support for supervising physicians, instead of relying on individual faculty members to manage the courses. Consequently, sustainability is limited by the capabilities of the faculty involved. A study investigating student experiences found that satisfaction was significantly higher with CBE than with hospital-based education, emphasizing the importance of government financial support and faculty development programs for supervising physicians [30]. This indicates that sustainable community-based practice requires stronger institutional support in the form of MOUs, budget allocations, and faculty development programs for supervising physicians.

Regarding opinions on community-based public healthcare institutional practice, the key findings were as follows. First, regardless of whether the school implemented practical education, there were no differences in the perception of the need for community-based practice or the positive impact of community-based practice on student understanding, interest, and career decisions in public healthcare. Our findings suggest that community-based practice is primarily implemented as a limited component of clinical clerkship, rather than as part of a systematic program that pervades the curriculum. Such limited exposure may not sufficiently contribute to students' understanding of and interest in public healthcare and appears to be insufficient to significantly influence their career decisions. Previous studies have indicated that long-term community-based practice positively influences attitudes toward community healthcare and related career choices [18]. Longitudinal integrated clerkship models that provide continuous exposure have been shown to have the greatest positive impact on career decisions in public healthcare [17]. These findings suggest that long-term exposure to community settings is essential in influencing career decisions. The structure of CBE in South Korea lacks such exposure, and thus may not effectively encourage students to pursue careers in public healthcare. To address this problem, planned long-term CBE beginning in the premedical years should be incorporated into the curriculum to foster career interests and commitment.

Second, we noted a strong preference for implementing community-based practice as practical courses spanning the premedical and medical years. Respondents emphasized understanding and participating in public healthcare projects based on community characteristics, as well as gaining an understanding of the public healthcare system through practical education. A study analyzing medical schools that the AMEE deemed exemplary found that the community-based learning experiences facilitated by those schools included broad exposure to community-related themes across admissions, curricula, learning experiences, and research [13]. These findings advocate for the integration into South Korean medical curricula of independent, structured courses that facilitate broad exposure to community settings. This requires a curriculum design and an implementation process that reflects the national public healthcare context. Although previous studies have proposed learning outcomes and practical formats for community-based programs based on expert consensus, implementation of these programs remains limited [28]. Future research aimed at evaluating the impact of community-based medical education should include the design and implementation of programs based on the findings of the present study.

Third, barriers to implementing community-based practice included issues related to practice institutions, as well as challenges in student and faculty perceptions and support for practical courses. The inadequate relationships between universities and practice institutions identified in this study underscore the importance of improving these relationships to support the successful implementation of practical education. Studies analyzing community-engaged medical education in other countries have highlighted the need for partnerships between medical schools and community practice institutions alongside formal agreements and regular interactions such as public discussions [31]. Additionally, challenges identified regarding supervising physicians included the need for cooperation between patients and hospitals, financial and time constraints, and a lack of guidelines for student education [28]. Universities and practice institutions must overcome these barriers by establishing formal partnerships through MOUs. Medical schools should also develop faculty training programs and operational guidelines for supervising physicians to encourage their participation in student education. On a broader scale, the government should expand its support for training public healthcare professionals through funding and policy measures for CBE. Addressing these barriers requires collaboration and engagement among medical schools, institutions, communities, and government bodies.

Finally, the opinions we collected on community-based practice emphasize the need for active participation, collaboration, and network building among communities, institutions, universities, students, and faculty. The respondents also highlighted the need for increased support, compensation, and funding for practical courses, as well as the necessity of strengthening public healthcare. Community-based practice plays a critical role in fostering social accountability in medical schools and requires active engagement and collaboration among all stakeholders. The importance of CBE has been discussed since the 1960s. The concept of community-engaged medical education has recently emerged with an emphasis on active community participation in medical school activities [31]. A notable example is the NOSM University, a Canadian institution that integrates community participation into program development, student selection, and practice, and has demonstrated positive outcomes in academic achievement and career choices [32]. In South Korea, disparities in healthcare facilities and the workforce persist, with 55.8% of physicians concentrated in metropolitan areas as of 2020 [33]. To address these imbalances, medical schools must expand their learning environments to include communities and strengthen their efforts to implement community-engaged education through collaboration with community stakeholders.

The limitations of this study include its focus on practices conducted in public healthcare institutions and the exclusion of other forms of CBE, which require further investigation. We also excluded information from eight nonparticipating medical schools, which should be considered when interpreting the results.

This study provides valuable insights into the status and requirements of community-based public healthcare institutional practice in South Korean medical schools. As the first study to comprehensively investigate this topic, our findings offer useful information for planning and implementing practical education programs. Collaboration and engagement among medical schools, practice institutions, communities, and government bodies are essential for addressing the limitations of community-based practice. Further research is required to develop and evaluate curricula designed to enhance CBE among South Korean medical students.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgment

This document was prepared as part of a research project titled “Development of a Community-Based Practicum Program for Prospective Healthcare Professionals in the Incheon Model,” commissioned by the Incheon Public Health Policy Institute.

Funding

This study was supported by funding from the Incheon Public Health Policy Institute as part of a project titled “Development of a Community-Based Practicum Program for Prospective Healthcare Professionals in the Incheon Model.”

Author contributions

Conceptualization, Formal analysis: SK, BC, SJY, Kyung Hye Park, Kwi Hwa Park; Data curation: SK, BC; Funding acquisition: SK, BC, SJY, Kwi Hwa Park; Methodology: SK, SJY; Supervision: Kyung Hye Park, Kwi Hwa Park; Validation: SK, BC, SJY; Writing-original draft: SJY; Writing-review & editing: SK, BC, SYK, SJY, Kwi Hwa Park

Fig. 1.

Word clouds of opinions on community-based practice at public healthcare institutions in medical schools.

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Figure & Data

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