Towards medical pedagogical pragmatism: transforming medical students’ Understanding of community health needs through the integrated longitudinal community clerkship in rural South Africa

Community-oriented medical education seeks to align medical training with priority community health needs and their lived realities. While longitudinal community-based clerkships are increasingly adopted to promote socially accountable graduates, there is limited qualitative insights into how these experiences can transform students’ understanding of community health needs, particularly in resource-constrained settings. This study explored how participation in a 20-week Integrated Longitudinal Community Clerkship at a South African medical school transformed medical students’ understanding of community health needs. Using a qualitative interpretivist design, data were generated from reflective journals, focus group discussions, observations, and field notes involving fifth-year medical students (n = 113) placed at district and regional hospitals in the Eastern Cape Province. Data were analysed using Braun and Clarke’s reflexive thematic analysis, informed by Scott’s transformative learning framework. Two analytically developed themes captured medical students’ transformative learning: (1) they demonstrated a paradigm shift by reframing illness and care from a predominantly biomedical orientation to a broader appreciation of social, cultural, and structural determinants of health, and (2) they articulated a shift from abstract, classroom-based knowledge to a contextualised and pragmatic understanding of community health needs, facilitated by prolonged immersion in under-resourced environments and supported mentorship. The findings show that longitudinal community immersion can catalyse transformative learning that reshapes how medical students conceptualise community health needs. Such experiences can enhance context-responsive clinical reasoning and practical judgment, contributing to a form of medical pedagogical pragmatism that can strengthen social accountability in medical education, particularly in underserved settings.