The tip of the iceberg: Generalism in undergraduate medical education, a systems thinking analysis.

Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 7605655 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1365-2923 (Electronic) Linking ISSN: 03080110 NLM ISO Abbreviation: Med Educ Subsets: MEDLINE

Publication: Oxford : Wiley-Blackwell
Original Publication: Oxford, Blackwell Scientific Publications.

Education, Medical, Undergraduate* ; Curriculum* ; Qualitative Research*; Humans ; Canada ; Systems Analysis ; Leadership ; Family Practice/education ; General Practice/education

Purpose: There is a shortage of generalist physicians globally impacting health equity and access to care. An important way in which medical schools can demonstrate social accountability is by graduating learners interested in careers in generalism. While generalism is endorsed as a matter of principle in medical education, how this translates into curricula is less clear. The aim of this study was to identify how generalism is understood and supported by family physician educational leaders in undergraduate medical education (UME) in Canada.
Methods: We conducted a qualitative study, interviewing 38 family medicine leaders in UME across all 17 Canadian medical schools. We examined the data with template analysis, informed by the iceberg model of systems thinking.
Results: Four themes were identified: (1) Teaching and learning strategies in support of generalism-a consistent range existed across UME curricula; (2) Curriculum patterns-changes in leadership and curriculum reform created positive or negative feedback loops that promoted or hindered initiatives to support generalism; (3) Curriculum structures-organ-system-based curricula and availability of generalist faculty presented particular challenges to teaching generalist approaches; (4) Mental models and ways of knowing-the preponderance of biomedical frameworks of thinking in curricula unconsciously undermined generalist approaches to patient care.
Conclusions: UME programmes promoted generalism through a range of teaching activities and strategies, but these efforts were countered by curriculum structures and mental models that perpetuate epistemic inequity between biomedical approaches to medical education and generalist models of care. Novel curricular frameworks are needed to align undergraduate programmes' commitment to social accountability with community-based need.
(© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Boelen C, Pearson D, Kaufman A, et al. Producing a socially accountable medical school: AMEE Guide No. 109. Med Teach. 2016;38(11):1078‐1091. doi:10.1080/0142159X.2016.1219029.
CaRMS. 2022 R‐1 Main Residency Match ‐ first iteration. Table 11: First choice discipline of CMG applicants [Internet]. 2022. [cited January 15, 2024]. Available from: https://www.carms.ca/wp-content/uploads/2022/06/2022_r1_tbl11e.pdf.
Marshall M, Ikpoh M. The workforce crisis in general practice. BJGP. 2022;72(718):204‐205. doi:10.3399/bjgp22X719213.
The Royal Australian College of General Practitioners. General Practice Crisis Summit: White paper [Internet]. East Melbourne, ; 2022 [cited 2024 January 15]. Available from: https://www.racgp.org.au/FSDEDEV/media/documents/Advocacy/General-Practice-Crisis-Summit-White-Paper-November-2022.pdf.
Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923‐1958. doi:10.1016/S0140‐6736(10)61854‐5.
Andermann A. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ. 2016;188(17–18):E474‐E483. doi:10.1503/cmaj.160177.
Starfield B. Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples' needs. Humanity & Society. 2009;33(1–2):56‐73. doi:10.1177/016059760903300105.
Boelen C. Coordinating medical education and health care systems: the power of the social accountability approach. Med Educ. 2018;52(1):96‐102. doi:10.1111/medu.13394.
World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030 [Internet]. : World Health Organization; 2016 [cited 2024 January 15]. Available from: https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf.
The Association of Faculties of Medicine of Canada (AFMC). FMEC 2020: One vision forward. Reigniting our common vision for the Future of Medical Education in Canada. Consultation Report August 2020 [Internet]. AFMC; 2020 [cited 2024 January 15]. Available from: https://www.afmc.ca/wp‐content/uploads/2022/10/2020‐FMEC_en.pdf.
PGME Collaborative Governance Council. Report on Generalism in Postgraduate Medical Education [Internet]. Post Graduate Medical Education Governance Council; 2018 [cited 2024 January 15]. Available from: https://pgme‐cgc.afmc.ca/sites/default/files/news/Generalism%20Working%20Group%20Position%20Paper%20FINAL.pdf.
NHS England. NHS Long Term Workforce Plan, June 2023 [Internet]. 2023 [updated 4 January 2024; cited 2024 January 15]. Available from: https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf.
Royal College of Physicians and Surgeons of Canada. Report of the Generalism and Generalist Task Force. Final Report: Definitions and Generalism and Generalist Education Strategy, Innovations, and Development Unit; 2013. [cited 7 May, 2024]. Available from: http://www.royalcollege.ca/rcsite/documents/educational-strategy-accreditation/ccc-task-force-report-july-2013-e.pdf.
Lawson E, Kumar S. The Wass report: moving forward 3 years on. Br J Gen Pract. 2020;70(693):164‐165. doi:10.3399/bjgp20X708953.
College of Family Physicians of Canada. Proceedings from the College of Family Physicians of Canada Undergraduate Education Retreat on Advancing Generalism, January 15, 2020 [Internet]. : College of Family Physicians of Canada; 2020 [cited 2024 January 15]. Available from: https://www.cfpc.ca/CFPC/media/PDF/2020-Undergraduate-Retreat-Proceedings-EN.pdf.
Alberti H, Cottrell E, Cullen J, Rosenthal J, Pope L, Thompson T. Promoting general practice in medical schools. Where are we now? Educ Prim Care. 2020;31(3):162‐168. doi:10.1080/14739879.2020.1744192.
IHS Markit Ltd. The Complexities of Physician Supply and Demand: Projections from 2019 to 2034. [Internet]. : Association of American Medical Colleges; 2021 [cited 2024 January 15]. Available from: https://www.aamc.org/media/54681/download?attachment.
Jager A, Harris M, Terry R. A rapid review of challenges faced by early‐career international medical graduates in general practice and opportunities for supporting them. BJGP Open. 2023;7(3):BJGPO.2023.0012. doi:10.3399/BJGPO.2023.0012.
O'Sullivan B, Russell DJ, McGrail MR, Scott A. Reviewing reliance on overseas‐trained doctors in rural Australia and planning for self‐sufficiency: applying 10 years' MABEL evidence. Hum Resour Health. 2019;17(8):8. doi:10.1186/s12960‐018‐0339‐z.
Querido SJ, Vergouw D, Wigersma L, Batenburg RS, De Rond MEJ, Ten Cate OTJ. Dynamics of career choice among students in undergraduate medical courses. A BEME systematic review: BEME Guide No. 33. Med Teach. 2016;38(1):18‐29. doi:10.3109/0142159X.2015.1074990.
Passi V, Johnson S, Peile E, Wright S, Hafferty F, Johnson N. Doctor role modelling in medical education: BEME Guide No. 27. Med Teach. 2013;35(9):e1422‐e1436. doi:10.3109/0142159X.2013.806982.
Shah A, Gasner A, Bracken K, Scott I, Kelly MA, Palombo A. Early generalist placements are associated with family medicine career choice: a systematic review and meta‐analysis. Med Educ. 2021;55(11):1242‐1252. doi:10.1111/medu.14578.
Dowell J, O'Malley A, MacFarlane AD, Gupta S. ScotGEM‐an update on Scotland's only graduate‐entry rural generalist‐focused undergraduate programme, including student career intentions. Rural Remote Health. 2023;23(1):8151.
Lamb EI, Alberti H. Raising the profile of academic general practice to our medical students. Br J Gen Pract. 2019;69(683):309‐310. doi:10.3399/bjgp19X704045.
McGrail MR, Chhabra J, Hays R. Evaluation of rural general practice experiences for pre‐vocational medical graduates. Rural Remote Health. 2023;23(1):1‐8. doi:10.22605/RRH7409.
Strasser R, Cheu H. Needs of the many: Northern Ontario School of Medicine students' experience of generalism and rural practice. Can Fam Physician. 2018;64(6):449‐455.
Monat JP, Gannon TF. What is systems thinking? A review of selected literature plus recommendations. Am J Syst Sci. 2015;4(1):11‐26. doi:10.5923/j.ajss.20150401.02.
Cottrell E, Alberti H. Cultural attitudes towards general practice within medical schools: experiences of GP curriculum leaders. Educ Prim Care. 2023;1‐8.
Mahood SC. Medical education: beware the hidden curriculum. Can Fam Physician. 2011;57(9):983‐985.
Misky AT, Shah RJ, Fung CY, et al. Understanding concepts of generalism and specialism amongst medical students at a research‐intensive London medical school. BMC Med Educ. 2022;22(1):291. doi:10.1186/s12909‐022‐03355‐1.
Kelly MA, Wicklum S, Hubinette M, Power L. The praxis of generalism in family medicine: six concepts (6 Cs) to inform teaching. Can Fam Physician. 2021;67(10):786‐788. doi:10.46747/cfp.6710786.
Kim DH. Introduction to systems thinking: leverage networks Inc. formerly Pegasus Communications, Inc; 1999.
Stalmeijer RE, McNaughton N, van Mook WN. Using focus groups in medical education research: AMEE guide no. 91. Med Teach. 2014;36(11):923‐939. doi:10.3109/0142159X.2014.917165.
Brooks J, King N. Qualitative psychology in the real world: The utility of template analysis. Paper presented at the British Psychological Society Annual Conference, 18‐20 April, 2012, London, UK. (Unpublished). 2012 [cited 2024 January 15]. Available from: http://eprints.hud.ac.uk/id/eprint/13656/1/.
King N. Doing template analysis. In: Symon G, Cassell C, eds. Qualitative Organizational Research. SAGE; 2012. doi:10.4135/9781526435620.n24.
Nutik M, Woods NN, Moaveni A, et al. Assessing undergraduate medical education through a generalist lens. Can Fam Physician. 2021;67(5):357‐363. doi:10.46747/cfp.6705357.
Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. The Annals of Family Medicine. 2003;1(1):4‐7. doi:10.1370/afm.47.
Ramanathan A, Clarke N, Foster M, et al. Operationalising generalism in medical education: a narrative review of international policy and mission documents. Educ Prim Care. 2023;1‐11. doi:10.1080/14739879.2023.2275262.
Osler W. The old humanities and the new science: the presidential address delivered before the classical association at Oxford, May, 1919. Br Med J. 1919;2(3053):1‐7. doi:10.1136/bmj.2.3053.1.
Hogenbirk JC, Strasser RP, French MG. Ten years of graduates: a cross‐sectional study of the practice location of doctors trained at a socially accountable medical school. PLoS ONE. 2022;17(9):e0274499. doi:10.1371/journal.pone.0274499.

Dept of Family Medicine, University of Calgary

Date Created: 20240615 Date Completed: 20241115 Latest Revision: 20241116

20250114

10.1111/medu.15463

38877994