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Changing patient demographics raise important challenges for healthcare providers around the world. Medical generalists can help to bridge gaps in existing healthcare provision. Various approaches to medical generalism can be identified, for example, hospitalists in the US and the restructuring of care away from medical disciplines in the Netherlands, which have different implications for training and service provision. Drawing on international debates around the definition and role of generalism, this article explores one manifestation of generalism in the UK to understand how abstract ideas work in practice and some of the benefits and challenges. Broad-based training is a two-year postgraduate training programme for doctors recently piloted in England. The programme provided 6-month placements in four specialties (general practice, core medicine, psychiatry and paediatrics) and aimed to develop broad-based practitioners adept at managing complex and specialty integration. Our longitudinal, mixed methods evaluation of the programme demonstrates that although trainees value becoming more holistic in their medical practice, they also raise concerns about being perceived differently by co-workers, and report feeling isolated. Using identity theory to explore the interplay between generalism and existing boundaries of professionalism in healthcare provision, we argue that professional identity, based on disciplinary structure and maintained by boundary work, troubles identity formation for generalist trainees who transcend normative disciplinary boundaries. We conclude that it is important to address these challenges if generalism in secondary care settings is to realise its potential contribution to meeting increasing health service demands.

There has been much discussion in this journal of the development of the scholarship of teaching and learning. Indeed the effective enhancement of teaching and learning is more likely to take place when generic lessons are contextualized within the language of the discipline, and adapted to the needs of the students. We describe here a study of the teaching practice of distance tutors on a History course, who were given the opportunity for extended reflection on the demands of the course, and to consider their aims and share their strategies, stimulated by ideas from threshold concepts and troublesome knowledge. In line with common practice in a distance environment, the reflection process took place in a workshop followed by participation in an online group, hosted on a wiki. We illustrate the significant or difficult areas of the course that staff reported, and describe their intentions and some of the strategies that they used for helping students with these critical areas. We propose a new approach to professional development which begins with reflection on the demands of the course itself and its students before considering appropriate facilitation strategies to meet those specific demands.