This study used the EDQ study design.²⁶ The researchers of this study found this design appropriate as it allowed the participants to contribute to the development of new knowledge (medical students and their preceptors’ understanding of ‘generalist medical practice’) in the training of UG medical students. At the time when this study was conducted, the researchers of this study had conducted a scoping study on the training of UG medical students on general medical practice and primary health care²⁵ and did not find studies that reported on what medical students and their trainers understood by ‘generalist medical practice’. Most literature addressed some aspects of this subject at postgraduate medical training.^8,9,10

This article focuses on one aspect of the principal researcher’s PhD project, which explored the training of medical students in generalist medical practice and primary health care (PHC) in South African medical schools. The study comprised four objectives: (1) what the UG medical students and their preceptors understood by ‘generalist medical practice’; (2) what the students and their preceptors understood by ‘primary health care’; (3) the experiences of the students and their preceptors regarding training in generalist medical practice and (4) the experiences of the students and their preceptors in primary health care training. This article reports on the first objective.

Four medical schools consented to participate in the study: Walter Sisulu University (WSU), Sefako Makgatho Health Sciences University (SMU) and the University of the Witwatersrand (WITS), including the University of KwaZulu-Natal (UKZN), which had secured a National Research Foundation (South Africa) grant. The UKZN had invited all universities with a medical school to a study to determine Transformation in Medical Education (TiME) in South Africa.²⁷ Transformation in Medical Education aimed at transforming medical education in South Africa to be on par with global developments in medical education. The emphasis was to produce socially accountable fit-for-purpose healthcare practitioners for the country. In this multiparticipatory collaboration, the principal researcher of this study wants to explore the training of UG medical students in generalist medical practice and primary health care. To this end, this study reports on the exploration of the understanding of the medical students and their preceptors regarding ‘generalist medical practice’. It is addressing one of the four objectives as explained earlier.

Regarding the medical schools, each is situated in a geographical location representative of the country’s diverse geopolitical spectrum: WITS mainly urban, WSU mainly rural, SMU mainly urban with a rural component and UKZN mainly rural with an urban.²⁸ Students and their trainers placed in different geopolitical environments have been found to encounter different geopolitical determinants of health and assume different approaches to meet those challenges.²⁹ The researchers explored the understanding of ‘generalist medical practice’ by students and their preceptors in the varying geopolitical environments within South Africa. Although this diverse geopolitical spectrum provided the described institutional variability, their selection was convenient,³⁰ rather than purposive,³¹ as it was based on their willingness to participate.

Regarding the principal researcher’s positionality, at the time of the study he was a family physician involved in the training of UG medical students in one of the four medical schools constituting the study setting. This position was declared to both the students and their preceptors during data collection. The principal researcher had no academic relationship with the participants in the other three medical schools.

Family Medicine, as a discipline, follows a generalist medical training approach among students,³² compared to specialist disciplines, which focus solely on their specialties; for example, obstetricians will confine themselves to the management of female patients pre- and peri-natally.³³ During his training of the medical students, the principal researcher developed an interest in finding out how the various disciplines (including Family Medicine) trained students in ‘generalist medical practice’, and particularly, in this article what they understood by this concept in their respective disciplines.

For reflexivity, the main researcher remained conscious of this position during data collection, analysis and interpretation.³⁴ Reflexivity has been defined as ‘the researcher’s ability to be able to self-consciously refer to him or herself in relation to the production of knowledge about research topics’.³⁵ For example, as a family physician, the principal researcher interviewed fellow family physicians with whom he shared the same specialty background. He had to be self-aware that conclusions are not based on the assumptions emanating from this background. Reflexivity was enhanced through jotting down all comments made by the participants, the researcher’s thoughts that came during and after the interviews, and making reflective summaries soon after each interview had been conducted.

The target population comprised the heads of departments (or their MBChB course coordinators) (Online Appendix 1) who were actively involved in the training of UG medical students in the major clinical disciplines mentioned in the introduction section earlier, as well as UG medical students in their clinical years of training (MBChB 4–6) (Online Appendix 2).

The expert purposive sampling strategy was used for both the students and their preceptors.³¹ The researchers intentionally recruited the students who were undergoing the training in their respective years of study and the preceptors who were involved in the former’s training. These were information-rich participants regarding the subject under study.³⁶ Student recruitment was performed through their class leadership who notified their colleagues and afforded the researchers the platform (physical or online) to contact the students. Recruitment of the students’ preceptors was arranged on a one-on-one basis per institution. Students’ FGDs were conducted in a lecture room of their choice, while the in-depth interviews with the students’ preceptors occurred in their offices. Twenty-seven in-depth interviews were conducted among the preceptors, while 16 FGDs, amounting to 102 students, were conducted at the four medical schools. Participation in this was voluntary.

Each FGD comprised five to eight students as recommended,³⁷ who were in their clinical years (MBChB 4–6). In each institution, one homogeneous FGD was arranged per year group (MBChB 4, 5 and 6), and the fourth FGD was heterogeneous, comprising about two students from each year group. The latter was performed to ensure maximum variability among the student groups.³⁶ Each in-depth interview and FGD lasted for an average of 1 h.

The principal researcher, assisted by a research assistant, collected data from 2016 to 2020 at the four medical schools: WSU 2016, WITS 2017–18, UKZN 2018–19 and SMU 2020. The research assistant was a 6-year medical student at the beginning of the study. He was being mentored by the principal researcher on research methodologies. His assistance ended when he qualified at the end of 2016. In this study, his main role was to take field notes and acquire students’ learning material from each medical school to corroborate information obtained through the interviews. The students’ guidelines varied in their curricular content per institution. However, that was not the focus of this study.

All interviews were conducted by the principal researcher. The exploratory question used to open discussions with each students’ preceptor was: ‘As a preceptor of undergraduate medical students, what is your understanding of generalist medical practice?’ An interview guide with prompts (Online Appendix 3) was used to focus the discussions on the study aim and objectives.

Regarding the FGDs conducted among the medical students, each comprised the recommended four to eight participants.³⁷ The exploratory question to open discussions was: ‘As undergraduate medical students in this institution, what do you understand by “generalist medical practice”?’ Similar to their preceptors, there were also prompts for the students (Online Appendix 3). The duration of each FGD was also similar to that of their preceptors.

Interviews with the last two students’ FGDs and the last three preceptors did not yield new information (data saturation).³⁸

All interviews were conducted in English, as it is the medium of instruction in all South African medical schools.³⁹ An audio recorder was used to capture the discussions. On a daily basis, the research team kept record of reflective summaries for both the students and their preceptors to identify developing themes.⁴⁰

All recorded interviews were transcribed verbatim. An expert in linguistics checked each transcript to ensure accurate transcription and to minimise typographical errors. The principal researcher used both the inductive and deductive methods of data analysis.⁴¹ The inductive data analysis method was used for the unstructured broad exploratory question on the understanding of ‘generalist medical practice’ by both the students and their preceptors,^42,43 while the deductive method was used for the preexistent semi-structured prompts,⁴⁴ derived from the global attributes of ‘generalist medical practice’. Data elicited through the last prompt in the interview guide, which enquired about ‘any other comment’ by a participant regarding their understanding of ‘generalist medical practice’, were also analysed inductively. The inductive analysis was conducted following the method recommended by Bingam, whereby codes were identified, arranged into categories and finally into themes.⁴⁵ Through deductive analysis, data were arranged according to the attributes of ‘generalist medical practice’ whereby the meaning of each attribute to the participants was recorded.⁴⁴ The MAXQDA 2020 (Analytics Pro) software programme was used in the data analysis, which yielded 2179 data segments.

As recommended for qualitative research studies,⁴⁶ trustworthiness of this study was ensured by consideration of credibility, dependability, confirmability and transferability. To ensure credibility, a data set was created (Appendix 4), containing the study findings for participant validation regarding the accuracy of the information. Dependability, which relates to reproducibility of data, was ensured by providing a thick description of the study methods. Confirmability, which pertains to objectivity of the researcher in data collection and interpretation,⁴⁷ was ensured by reflexivity, whereby the researcher was self-conscious of his influence on the participants as a trainer of medical students himself, allowing independent expression among all participants. For example, some students would clearly express their views that they did not think highly on generalist practitioner preceptors as they regarded them as lacking in knowledge and skills, compared to their specialist counterparts. The main researcher, himself a generalist practitioner, would acknowledge their viewpoint and never engage them in counterarguments. Transferability, the degree to which the study conclusions are applicable to other similar settings⁴⁶ was ensured by providing sufficient description of the study setting and participants (thick description).⁴² Data triangulation was achieved through field notes taken during the interviews and reference to the students’ training manuals obtained from each medical school.⁴⁷ Furthermore, the different participants (students and their preceptors) and methods used in data collection (FGDs and in-depth interviews) enhanced triangulation.

Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (No. HSS/2187/017D). This study was performed in line with the principles of the Declaration of Helsinki. Participation in the study carried no risk to the students. However, the study’s findings on the understanding of medical students and their trainers on ‘generalist medical practice’ could add an important dimension to the body of knowledge on the subject. Each consenting student and preceptor was requested to sign a written consent form for participation. Each participant was assured of the confidentiality of the information and that data storage for both electronic and hardcopy formats would be secured.

Students explained their understanding of generalist medical practice by describing the role of this care:

They further elaborated: ‘So, for example when you rotate in orthopedics, you get the basic knowledge required of a generalist practitioner of how to manage basic orthopaedic cases’ (WSSM6.1, MBChB 6, 29 years). With basic knowledge of medicine, the generalist practitioners were further explained as ‘not specialised’ in any particular medical field, which was a limitation in their knowledge and skill:

In remaining on the basics required of generalist practitioners, one specialist preceptor admitted that his aim in the training of the UG medical students was not to turn them into ‘mini specialists’, but to give them basic medical education, taking into consideration that they were trainees who would exit their training with a generalist overview of medicine. He further highlighted the need for the training exposure to be in primary health care, rather than in specialist centres:

Students asserted that generalist practice was the first point of patient contact with the healthcare system: ‘Generalist practice forms part of the first point of care which a patient would refer to when they’re having a problem’ (KZNS4.1, MBChB 4, male student, 21 years), and:

Students gave an account of the incremental nature of the complexity of conditions of the patients they encountered in primary health care settings, like clinics: ‘I think that’s very important in medicine, … we have that [training] occurring in different years, … more and more as you progress in your medical school career’ (KZSM6.2, MBChB 6, female student, 26 years).

The student preceptors were also aligned with this understanding: They’re [generalist practitioners] important as they are the first entry of any patient going into the health system’ (CSMT2, clinical preceptor, Psychiatry), and:

As the first point of patient contact, the generalist practitioner was dealing with a wide range of medical conditions, which were described by students as general (not specialised), common and minor.

General conditions were explained as ‘anything that comes from the community …, any presentation from … any patient who comes in fresh from outside, even if they have their own chronic conditions’ (KZS5.3, MBChB 5, female student, 23 years). This called upon the generalist practitioner to possess an ‘all-disciplines’ competency:

This scenario was thought to reflect the UG medical training in South Africa:

The wide range of conditions also entailed common conditions: ‘My understanding … is, a generalist practitioner is basically a doctor who can function in any discipline and manage the common conditions that arise’ (KZS5.5, MBChB 5, male student, 24 years). There were various explanations on what qualifies a ‘common condition’, such as those indicated in students’ guidelines:

And also, those conditions that were seen as prevalent in various communities, as determined by studies that had been conducted in those communities: ‘So, we would learn the conditions that are common in these communities’ (WTS5.3, MBBCh 5, male student, 23 years).

The wide range of conditions were further described as comprising ‘minor conditions’, which were understood as those that had low mortality and did not progress rapidly to kill a patient:

Students stated that, because generalist practitioners’ knowledge and skills were limited, they could only deal with minor uncomplicated conditions: ‘They [generalist practitioners] could be limited in skills, knowledge and experience with very complicated conditions that would usually be referred onward to the specialists’ (SMS6.1, MBChB 6, male student, 24 years). This limitation was viewed as potentially dangerous to a patient: ‘because sometimes generalists tend to ignore or mismanage certain conditions because they sort of lack the basic background’ (WSS5.4, MBChB 5, female student, 24 years). Students provided what they thought was the reason for the limitation – the limitation in resources at that level:

Students’ preceptors also attested to the ‘broad base’ of common medical conditions manageable at a generalist level, which they understood to characterise generalist medical practice:

And:

and ‘for each discipline, we make sure that the … common conditions are covered and [at] what scales we’ll be teaching the students’ (AWST5, clinical preceptor, Paediatrics).

Students also mentioned the ‘advocacy for patients’ role of a generalist practitioner, which their preceptors did not mention. The students highlighted the advocacy role as ‘fighting’ for patients’ rights:

The common understanding of the students and their preceptors on ‘generalist medical practice’ could be explained through Vygotsky’s social constructivist theory, given that the students came to the medical schools as ‘novices’ in the field of medical practice and gained the understanding through interaction with their ‘knowledgeable others’, the latter communicating these attributes to the students.

Lave and Wenger’s theory of ‘situated learning’ also gave insight into the understanding of the students and their preceptors regarding ‘generalist medical practice’.²⁴ The ‘situated learning’ theory was the fulcrum around which the student learning occurred. Students learnt in the company of peers and preceptors and learnt their understanding of generalist medical practice in that situation. Through legitimate peripheral activities, the novices become acquainted with the tasks, vocabulary and organising principles of the community’s practitioners. Language (medical jargon and tradition) was the central part in the CoP.²⁴ The theories have been referred to in the following paragraphs.

The researchers in this study searched for comparative literature on the subject of generalist medical practice among students and their preceptors. In high-income countries, generalist medical practice (also referred to as ‘generalism’) at UG medical training is discussed mainly with the view to prepare students to follow a postgraduate career in general practice (GP),^15,48 different from the low- and middle-income countries (including South Africa)⁴⁹ where postgraduate specialisation in general medical practice is not necessarily a prerequisite for general practice.^50,51 Literature indicates that students perceived ‘generalism’ to be of lower prestige in the medical profession.^52,53,54 These perceptions were already present at the very start of medical school and seemed to be reinforced during UG training.¹⁵ The researchers of this study could not find studies conducted on medical students’ and their preceptors’ understanding of ‘generalist medical practice’. The literature they found focused mainly on the involvement of general practitioners in UG medical training.^55,56 Therefore, there was limited opportunity to draw international comparisons on the subject.

The fact that students understood generalist medical practice as a limitation in the practice of medicine as they perceived it to only relate to basic and shallow knowledge of medicine needs to be put into its proper perspective. Through this basic medical knowledge, generalist medical practitioners cater for the needs of the majority in the community, and if implemented appropriately, can ensure efficiency of the healthcare systems in solving problems before they require specialised care as has been shown in literature.⁵⁷ Therefore, rather than it being viewed as a limitation, it should be viewed as the strength of generalist medical practice.

The study’s finding that specialist preceptors indicated that they were not training students to turn them into ‘mini specialists’, but to give them basic medical education, was reassuring for generalist medical practice training. It should be encouraged in UG medical student training, as studies have shown that student preceptors themselves require training to be appropriate teachers.^58,59

Students understood generalist medical practice as the first portal of entry of patients into the health system where patients are ‘filtered’. The filtering referred to patient screening for early detection of individuals with unrecognised diseases, as well as those with early stages of disease in the population.³⁴ Student preceptors added that they guided students on the approach in dealing with these patients to enable them to identify a broad base of conditions spanning over many disciplines. Some of them may be medical emergencies needing stabilisation before referral to more specialised centres. This aspect of generalism is crucial in the training of medical students as it prompts them to think comprehensively,³⁵ thus enhancing patient safety.³⁶ In this way, student preceptors were taking the students through the ZPD to the level of expertise in patient care.²⁵

Students further understood generalist medical practice as the field of medical practice dealing with ‘minor ailments’ which has been defined in literature as ‘conditions that will resolve on their own and can be reasonably self-diagnosed, for example, heartburn, nasal congestion, headache, etc.’³⁷ However, some students also stated that they understood ‘minor ailments’ to be those that are ‘not complicated’. In this regard, their preceptors need to caution them, as there could be underlying complex conditions among those that may appear ‘minor’.³⁸ To this effect, students need to be trained on the importance of knowing the natural history of an illness. This will entail the pattern of an illness that encompasses both its early and late presentations. This knowledge about the dynamic nature of illnesses over time will enable students to give appropriate safety-netting advice to their patients.⁶⁰ A classic example would be a minor head injury where a patient is asked to look out for early symptoms and signs of worsening of the condition, such as drowsiness or inability to wake up.⁶¹ In such conditions, students need training to caution the patient and/or next-of-kin to report back immediately to the health facility when these occur for prompt intervention to be undertaken.

Furthermore, students and their trainers recognised the role of a generalist medical practitioner in managing emergency medical conditions. They provide the necessary treatment to those manageable within their scope of practice, stabilise and refer those who require specialised care. For the patient identified as requiring referral, evidence indicates that a generalist practitioner who has proper skills in patient referral, including transport arrangement and communication with the receiving hospital, prevents unnecessary delays, which would otherwise compromise patient care.⁶²

Both students and their preceptors understood the generalist medical practitioners to be dealing with the undifferentiated patient, whose condition needed proper assessment to determine treatability at generalist level or otherwise referral to the relevant specialties. The students’ preceptors leveraged that common understanding to guide students to implement their hitherto acquired clinical skills to work out for themselves a label (diagnosis) for the patient and to indicate their suggested management plan. There is evidence that UG medical students benefit from exposure and familiarisation with undifferentiated patients who are described as ‘patients walking through the door’, as these are the types of patients they will frequently encounter in generalist medical practice.⁶³ Dealing with an undifferentiated patient provides students the opportunity to learn clinical reasoning, which entails synthesising the acquired information and skills to reach new conclusions about a patient’s condition.²⁵ In this manner, Vygotsky’s ‘scaffolding’ principle becomes demonstrable, whereby students are taken through clinical conditions of gradual complexity.²¹

Regarding continuity of care, students understood that the generalist medical practitioner has the opportunity to establish a lifelong relationship with his or her patients from cradle to grave.⁶⁴ Continuity of care challenged the students to be lifelong learners, given ‘the shifting ecology of the medical environment’.⁶⁵ In keeping with their students, students’ preceptors understood continuity of care as relating to patient follow-up and building a continuing doctor–patient relationship with their patients. This addresses the important aspect of commitment to the patient as a person, rather than only their clinical conditions.⁶⁶ Another attribute related to continuity of care is coordination of care, whereby a practitioner plays a key role in coordinating the team of healthcare professionals to potentiate patient care across diseases, settings and clinicians.⁶⁷ The students were thus initiated to the concept of the ‘community of practice’ proposed by Wenger,⁶⁸ enabling them to identify appropriate members of this community according to their role in the medical field. In coordinating patient care, the generalist medical practitioner ensures that patients’ right of access to available resources is ensured.^69,70,71,72 In South Africa, commitment to coordination of care by generalist medical practitioners, including nurse practitioners, was found to be inadequate among generalists practicing in Cape Town in 2018.⁷³ This is a call to ensure emphasis on coordination of patient care among all healthcare practitioners beginning at UG training level.

Regarding holistic patient care, students understood it as taking into consideration factors beyond the clinical conditions that patients presented with, namely the psychosocial aspects. It is the duty of the generalist medical practitioner to adopt a holistic management approach, given the undifferentiated nature of the patients’ conditions they frequently encounter.⁷⁴ Students’ preceptors described holistic patient care as the bio-psycho-socio-spiritual care. To this end, they ensured that student training did not only focus on the clinical conditions that patients presented with but also on the other patient aspects identified by the WHO in the definition of health, namely the mental and social aspects,⁷⁵ which have also been described as the patient’s existential dimension.⁹

The students and their preceptors understood ‘generalist medical practice’ to also entail health promotion and disease prevention. Literature indicates that these attributes link directly with the social determinants of health (SDH), such as water and sanitation, the inaccessibility of which frequently results in disease occurrence.⁷⁶ This implies that health promotion and disease prevention cannot be adequately achieved without addressing these. In South Africa, the re-engineering of primary health care was introduced to increase access of health services to the general public, to address the SDH, thus improving the quality of health services in general.⁷⁷ Nevertheless, the students’ and their preceptors’ understanding of interprofessional collaboration of various sectors to address the SDH fell outside the scope of this study, but should be considered in further studies.

Students also understood the value brought by a generalist medical practitioner in primary health care, whereby the generalist’s competence encompasses a wide range of clinical disciplines and procedural skills requisite at primary health care in both chronic and emergency care, as also recorded in literature.²⁰ This understanding could be leveraged on by the students’ preceptors in making the students understand the interconnectedness of generalist medical practice and primary health care.⁴⁸ A practitioner serving in primary health care needs to understand the scope of the generalist medical practice. That understanding has been shown to set the scene in the delivery of comprehensive medical care.⁷⁸

The study was conducted on only four of the nine medical schools in South Africa which limits transferability of the study findings. The variability of medical education among institutions necessitates caution in generalising the study’s findings to encompass the opinions of all medical students and their preceptors nationwide. Data collection occurred over a period of 5 years, which is the study limitation in terms of data consistency, as ideas of students and their preceptors could have developed and varied over this period. During the interviews, social desirability bias could have been introduced on the part of the medical students,⁷⁹ whereby they could have behaved in a manner they thought would be acceptable to the principal researcher. The principal researcher was himself a preceptor. As far as the authors are aware, this is the first study conducted on the subject in South Africa.

The understanding of ‘generalist medical practice’ by medical students and their preceptors relating to the attributes discussed earlier was not dissimilar to the global understanding recorded in literature. However, the understanding that ‘generalist medical practice’ deals with uncomplicated medical conditions needs to be coupled with caution that ‘uncomplicated’ may turn out to have underlying complications. The understanding of ‘generalism’ as connoting ‘shallowness’ in medical knowledge and skills also needs correction. While it is true that ‘generalism’ deals with general (nonspecialised) medical conditions,⁷⁵ emphasis should lie on training medical students to recognise medical conditions falling into the ‘generalist’ and ‘specialist’ categories to facilitate appropriate management – all in the interest of optimum patient care.