What you legitimise is what you get: A case study of an undergraduate medical curriculum in South Africa.

INTRODUCTION: Many medical graduates are entering practice not ready in the ways that count. The prevailing explanation is a lack of opportunity for clinical experience, but this rationale is insufficient in resource constrained, high-volume clinical training contexts. What is legitimised will ultimately shape what is learned. This study aimed to explore what forms of knowledge, participation, and ways of being are legitimised within a medical curriculum in South Africa. METHOD: We conducted explanatory, instrumental case study research using multiple sources of data from one medical school in South Africa. 21 Final-year medical students took part in four focus groups, 12 clinical training coordinators took part in semi-structured interviews and 20 documents conveying expectations to final-year medical students were collected from the online learning management system between March and August 2025. Data were analysed using thematic analysis, using Legitimation Code Theory (LCT) as a theoretical framework. RESULTS: Three key themes were identified: (1) medical school aspires to ready graduates with the holistic range of competencies required in practice (2) structural constraints privilege performance in assessments over participation and (3) both students and clinical teachers experience delegitimization in the clinical training environment. There is a misalignment between intended outcomes, where both knowledge and ways of being are valued, and an enacted and experienced legitimacy, where achievement is defined through performance in high-stakes assessments. This shift privileges 'what you know' while devaluing 'who you are,' resulting in the marginalisation of the competencies required for a successful transition to practice. DISCUSSION: Clinical exposure is not enough to ensure students gain the experience they need to be prepared for practice, what is legitimised will determine whether intended learning takes place. Curriculum innovation and culture change aimed towards legitimising student participation and professional development can allow for the potential of clinical training environments to be realised.