Why internal medicine training struggles to deliver generalism: structural barriers and implications for workforce...

Higher specialty internal medicine (IM) training has been expanded to meet growing demand for generalist physicians, yet educational environments remain inconsistent and trainees report dissatisfaction. Little qualitative work has explored why IM training struggles to develop generalist capability as intended. This study examines how IM residents and trainers understand the purpose of IM training, how they experience it, and what conditions shape development.

We conducted a qualitative study informed by an interpretivist paradigm. Semi-structured interviews were conducted with 23 participants (16 residents, 7 trainers) from 17 hospitals across London and Kent, Surrey, and Sussex between October 2024 and January 2025. Data were analyzed using reflexive thematic analysis.

Four themes were identified. Conceptual ambiguity: participants struggled to articulate what generalism means or how IM training would extend their capabilities. Fragmented educational structures: lack of supervisor-trainee continuity and limited supervision undermined learning, with the apprenticeship model largely collapsed. Cognitive and emotional overload: acute take workloads were cognitively overwhelming, precluding reflection and producing emotional erosion. Specialty-IM conflict and identity tension: IM commitments were perceived to displace specialty learning, generating resentment, and disengagement across specialty groupings.

IM training, as currently structured, appears misaligned with its intended purpose. Findings raise concern that the programme risks producing specialists who are disillusioned with generalism and insufficiently equipped to deliver it. Six priorities for reform are proposed, focusing on curricular clarity, protected specialty time, structured IM blocks, rebuilt apprenticeship structures, reduced cognitive overload, and strengthened accountability for educational funding. Key messages What is already known on this topic: Survey-based evidence shows that higher specialty internal medicine (IM) training is associated with poor teaching scores, trainee dissatisfaction, and tension between generalist and specialty development. What this study adds: This in-depth qualitative study identifies four inter-related structural and cultural mechanisms (conceptual ambiguity, fragmented educational structures, cognitive and emotional overload, and specialty-IM identity conflict) through which IM training undermines the development of generalist identity and capability. It reframes trainee disengagement from generalism as structural rather than ideological: residents did not reject generalism itself, but the conditions in which it is currently practised and taught. How this study might affect research, practice, or policy: The findings suggest six priorities for reform: clarifying curricular purpose, protecting specialty training, delivering IM in defined blocks, rebuilding apprenticeship, reducing cognitive overload, and strengthening accountability for educational funding. Further research at greater scale is needed to test whether these findings generalize across the UK training landscape. Main messages IM training struggles to deliver generalism not because trainees reject it, but because the conditions in which it is taught and practised undermine it. Four interacting mechanisms - conceptual ambiguity, fragmented educational structures, cognitive and emotional overload, and specialty-IM identity conflict - explain why dissatisfaction with IM training recurs despite policy efforts. Trainee disengagement from generalism is structural rather than ideological, and is therefore should be treated as an educational design problem rather than a communications problem. Future research questions Do the four mechanisms identified here - conceptual ambiguity, fragmented educational structures, cognitive and emotional overload, and specialty-IM identity conflict - operate similarly across UK regions beyond London and KSS? How is generalist professional identity formed (or not) over the course of higher specialty training, and what experiences do trainees describe as pivotal in shaping whether they come to identify as generalists? How do trainees who report positive experiences of IM training describe the conditions that made those experiences possible, and what can these "positive deviant" cases reveal about what good generalist training looks like in practice? How do consultants and educational leaders interpret the tension between service provision and education, and how do they navigate competing pressures when designing rotas and placements, or working clinically with residents?