The study has demonstrated that students and their trainers shared a common understanding of PHC as the patient’s first point of contact with the healthcare system, comprehensive care, coordination of care and continuity of care. There were various opinions among both groups on whether PHC was to be regarded a level, an approach, or a combination of both, towards health care. Some students expressed a view that specialists should be involved in PHC training while others were uncertain. There were distinctly contrasting views among their trainers in this regard.
Both students and their trainers understood PHC as the first point of patient entry into the healthcare system, in keeping with the view held by the WHO [1], and many countries [26–29]. As the point of first patient contact, students indicated that PHC necessitated training in common and uncomplicated medical conditions. Their trainers referred to these conditions as “any medical condition,” to convey the idea of an “undifferentiated patient,” which characterizes PHC [30, 31]. Students also indicated that PHC was optimally practiced in community facilities, and consequently viewed their training mainly based in tertiary institutions as taking them away from the PHC training platforms. Indeed, the approach of tertiary institutions towards patient care has been reported as curative and facility-based, compared to the community-based health care which emphasizes disease prevention and health promotion [32].
Some students mentioned that PHC was comprehensive care in that it took into consideration not only the patient’s disease, but their contexts as well. One student trainer used the term “the biopsychosocial aspect” to describe the same phenomenon. The University of Putra in Malaysia has demonstrated that medical education should incorporate both medical science and social science disciplines to equip students to understand the multifaceted nature of disease conditions [33]. At that university, students were trained to arrive at a patient diagnosis that was not only based on physical examination for clinical signs and symptoms, as that approach fell short of addressing the patient’s needs comprehensively. In this study, students also mentioned social determinants of health as forming part of comprehensive care. Student trainers added the need for a clinician to attend to the patient’s lifestyle modifications which they viewed as linked to the SDH. There is literature evidence of this link particularly among the elderly [34]. Rasanathan et al., have already demonstrated that social determinants of health and PHC are priorities in addressing health equity in communities [35]. Therefore, successful reduction of health inequities is achieved through intentional redress of social determinants of health in communities. In mentioning SDH, students also indicated the need for patients to be empowered through patient advocacy. Patient advocacy was explained as empowerment of patients through education on their conditions, enabling them to be partners in the management. A recently conducted scoping review has shown that patient education is an effective tool in empowering patients with chronic diseases for self-management [36]. This understanding of PHC by both the students and their trainers augurs well for a good foundation in PHC training in South Africa.
Students understood coordination of care as when a PHC practitioner with a generalist medical approach takes leadership in ensuring the collaboration of various disciplines to optimize patient care. In keeping with the students’ view, the pivotal role of a generalist in the integration of multidisciplinary patient care has been described [37]. However, the student trainers understood coordination of care as the practice of team-based health care which was not solely reserved for the doctor – it could be any appropriate healthcare practitioner in a given clinical situation. The view of the student trainers was that a coordinator should be decided on by collegial consensus. The position of the trainers is backed by a recent study conducted on 60 healthcare teams which demonstrated that in a multi-disciplinary healthcare team, the discipline with “the most pertinent expertise relative to the topic under discussion” should take leadership [38]. It is the view of the authors that the trainers in the four South African medical schools have the responsibility to alert their students on the importance of collaborative decision-making on team leadership to break down the historically entrenched hierarchies in medical care, whereby medical doctors’ decision-making processes were perceived unchallengeable [39].
Students and their trainers understood continuity of care as the establishment of a continuing relationship with a patient, taking the responsibility of making follow-ups on the patient’s well-being beyond the first encounter. This informed the training methods students received: making follow-up enquiries when patients were up referred to specialist care or when they were discharged home. There is acknowledgment that it is difficult to provide longitudinal care experiences among students, given the dynamic nature of the training platforms whereby patients are lost to follow-up for various reasons [40–42]. In a study that explored the views of patients who were allocated students to provide them with continuity of care, it was shown that patients valued the relationship with students similar to that described between patients and their qualified physicians [43]. The patients appreciated the role played by students in linking them up with their physicians, while the students also benefitted in the training in continuity of care [43]. In our study, the dovetailing understanding of continuity of patient care between the students and their trainers displayed the potential to set the scene for effective student training in that regard.
Regarding the understanding of PHC as a level of care or an approach to healthcare, the divergent views were found among both the students and their trainers. Literature indicates that primary care and PHC cannot be used interchangeably [44, 45]. The former refers to a level of care offered by a healthcare practitioner to individuals and families [46], while the latter seeks to address people’s social and economic systems, hence the underlying social determinants of health, towards provision of affordable and sustainable health care [47]. The aspirations of PHC have been addressed in the WHO definition of PHC as “the whole-of-society approach in health, aimed at providing equitable health and well-being to individuals, families and communities, as early as possible in the continuum of health, namely health promotion, disease prevention, curative, rehabilitative and palliative care, as close as feasible to people’s day-to-day environments”[48]. In their understanding of PHC, the trainers and their students need to come to terms with this global definition of PHC by the WHO as an approach, not a level of health care, and reflect that understanding in student training on PHC.
There were differences of opinion among the students on whether specialists should be involved in PHC training, with some holding the view that specialists should be involved, while others expressing their doubt. We did not find studies which reported on the views of medical students on the appropriateness of the involvement of specialist trainers in PHC training. However, there is a global move towards training medical students in PHC in decentralized healthcare units outside of hospitals [49], where the majority of the student trainers are generalists [50]. Some specialist trainers felt they had a role to play in PHC, citing that they were capable of executing some PHC functions, like immunization of children. The preventive function of specialists has also been reported in Europe [51]. However, other specialist trainers were of the strong view that PHC was not their territory, arguing that they had limited time to practice comprehensive patient care required for PHC. It has been suggested that the solution to these divergent views between generalists and specialists could be the establishment of interdisciplinary collaborations [52]. The authors are of the view that specialists form a crucial component in this collaboration, as they role-model students towards specialization, which is also a need in communities.
The limitation of the study was that it was conducted in four of the nine medical schools in South Africa. Although the invitation had been extended to all the medical schools, only those accepted the invitation. Therefore, the study findings cannot be generalized to the other South African medical schools, but are only transferrable under similar contexts. However, the geographical locations of each medical school (mainly rural, mixed but mainly rural, mixed but mainly urban and mainly urban – reported in the methodology section), reflecting the respective student catchment areas, was fairly representative of the whole geographical spectrum of the country. Social desirability bias on the part of students was unavoidable, given that they were interviewed by a student trainer, albeit from a different institution in three of the institutions.