"It is this very knowledge that makes us doctors": an applied thematic analysis of how medical students perceive the relevance of biomedical science knowledge to clinical medicine

BACKGROUND

Intensive study of the biomedical sciences remains a core component of undergraduate medical education with medical students often completing up to 2 years of biomedical science training prior to entering clerkships. While it is generally accepted that biomedical science knowledge is essential for clinical practice because it forms the basis of clinical reasoning and decision-making, whether medical students perceive an expanded role for their biomedical science knowledge remains to be examined.

METHODS

We conducted a qualitative research study to explore how medical students in the first clerkship year perceived the relevance of biomedical science knowledge to clinical medicine during this pivotal time as they begin their transition from students to physicians. To identify previously unidentified perspectives and insights, we asked students to write brief essays in response to the prompt: How is biomedical science knowledge relevant to clinical medicine? Ten codes and four themes were interpreted through an applied thematic analysis of students' essays.

RESULTS

Analysis of students' essays revealed novel perspectives previously unidentified by survey studies and focus groups. Specifically, students perceived their biomedical science knowledge as contributory to the development of adaptive expertise and professional identity formation, both viewed as essential developmental milestones for medical students.

CONCLUSIONS

The results of this study have important implications for ongoing curricular reform efforts to improve the structure, content, delivery, and assessment of the undergraduate medical curriculum. Identifying the explicit and tacit elements of the formal, informal, and hidden curriculum that enable biomedical science knowledge to contribute to the development of adaptive expertise and professional identity formation will enable the purposeful design of innovations to support the acquisition of these critical educational outcomes.

Near and Far Transfer in Cognitive Training: A Second-Order Meta-Analysis

Theory building in science requires replication and integration of findings regarding a particular research question. Second-order meta-analysis (i.e., a meta-analysis of meta-analyses) offers a powerful tool for achieving this aim, and we use this technique to illuminate the controversial field of cognitive training. Recent replication attempts and large meta-analytic investigations have shown that the benefits of cognitive-training programs hardly go beyond the trained task and similar tasks. However, it is yet to be established whether the effects differ across cognitive-training programs and populations (children, adults, and older adults). We addressed this issue by using second-order meta-analysis. In Models 1 (k = 99) and 2 (k = 119), we investigated the impact of working-memory training on near-transfer (i.e., memory) and far-transfer (e.g., reasoning, speed, and language) measures, respectively, and whether it is mediated by the type of population. Model 3 (k = 233) extended Model 2 by adding six meta-analyses assessing the far-transfer effects of other cognitive-training programs (video-games, music, chess, and exergames). Model 1 showed that working-memory training does induce near transfer, and that the size of this effect is moderated by the type of population. By contrast, Models 2 and 3 highlighted that far-transfer effects are small or null. Crucially, when placebo effects and publication bias were controlled for, the overall effect size and true variance equaled zero. That is, no impact on far-transfer measures was observed regardless of the type of population and cognitive-training program. The lack of generalization of skills acquired by training is thus an invariant of human cognition.

Does chess instruction improve mathematical problem-solving ability? Two experimental studies with an active control group

It has been proposed that playing chess enables children to improve their ability in mathematics. These claims have been recently evaluated in a meta-analysis (Sala & Gobet, 2016, Educational Research Review, 18, 46-57), which indicated a significant effect in favor of the groups playing chess. However, the meta-analysis also showed that most of the reviewed studies used a poor experimental design (in particular, they lacked an active control group). We ran two experiments that used a three-group design including both an active and a passive control group, with a focus on mathematical ability. In the first experiment (N = 233), a group of third and fourth graders was taught chess for 25 hours and tested on mathematical problem-solving tasks. Participants also filled in a questionnaire assessing their meta-cognitive ability for mathematics problems. The group playing chess was compared to an active control group (playing checkers) and a passive control group. The three groups showed no statistically significant difference in mathematical problem-solving or metacognitive abilities in the posttest. The second experiment (N = 52) broadly used the same design, but the Oriental game of Go replaced checkers in the active control group. While the chess-treated group and the passive control group slightly outperformed the active control group with mathematical problem solving, the differences were not statistically significant. No differences were found with respect to metacognitive ability. These results suggest that the effects (if any) of chess instruction, when rigorously tested, are modest and that such interventions should not replace the traditional curriculum in mathematics.

Memory for Patient Information as a Function of Experience in Mental Health

Mental health clinicians are tasked to diagnose and treat the millions of people worldwide seeking help for mental health issues. This paper investigates the memory clinicians have for patient information. We hypothesize that clinicians encapsulate mental health knowledge through experience into more abstract concepts, as in other domains changing what clinicians remember about patients compared with non-professionals. We tested memory for realistic patient-therapist interactions in experienced clinicians, intermediately trained graduate students, and laypeople. Clinicians recalled fewer facts than intermediate trainees and as many as laypeople. Furthermore, clinicians reported more abstracted information than all other participants, providing the first empirical demonstration of knowledge encapsulation in the memory of mental health clinicians. We discuss how our results fit into the existing literature on clinical expertise in mental health and the implications of our findings for future research relevant to mental health care.

Assessing patient management plans of doctors and medical students: an illness script perspective

INTRODUCTION

Illness script theory offers explanations for expert-novice differences in clinical reasoning. However, it has mainly focused on diagnostic (Dx) performance, while patient management (Mx) has been largely ignored. The aim of the present study was to show the role of Mx knowledge in illness script development and how it relates to diagnostic knowledge in the course of development toward expertise.

METHODS

The participants were 10 fourth-year and 10 sixth-year medical students, and 10 experienced physicians (ie, internists). Participants were asked to study 4 written clinical cases and provide management plans. Based on propositional analysis the management plans were examined for accuracy and elaborateness as well as the number of Mx and Dx items.

RESULTS

Providing accurate Mx plans that concurrently pay attention to Dx and Mx was a characteristic of doctors' performance. The Mx plans of sixth-year students were as accurate as fourth-year students, but the format and the size of sixth-year students' plans was more similar to those of doctors. While sixth-year students generated plans with an Mx focus, the plans of fourth-year students were characterized by a Dx focus.

DISCUSSION

The experienced physicians' accurate management plans are characterized by a high number of the Mx and Dx items. For sixth-year students the management plans are still incomplete, which leads to generic as well as inaccurate Mx orders. For fourth-year students, the Mx focus is lacking, and hence they seem to treat an Mx task as if it were a Dx task.

Sherlock Holmes - an expert's view of expertise

In recent years, there has been an intense research effort to understand the cognitive processes and structures underlying expert behaviour. Work in different fields, including scientific domains, sports, games and mnemonics, has shown that there are vast differences in perceptual abilities between experts and novices, and that these differences may underpin other cognitive differences in learning, memory and problem solving. In this article, we evaluate the progress made in the last years through the eyes of an outstanding, albeit fictional, expert: Sherlock Holmes. We first use the Sherlock Holmes character to illustrate expert processes as described by current research and theories. In particular, the role of perception, as well as the nature and influence of expert knowledge, are all present in the description of Conan Doyle's hero. In the second part of the article, we discuss a number of issues that current research on expertise has barely addressed. These gaps include, for example, several forms of reasoning, the influence of emotions on cognition, and the effect of age on experts' knowledge and cognitive processes. Thus, although nearly 120-year-old, Conan Doyle's books show remarkable illustrations of expert behaviour, including the coverage of themes that have mostly been overlooked by current research.

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.

The role of pathophysiological explanations in clinical case representations of dental students and experts

INTRODUCTION

Teaching of biomedical knowledge lays the foundations for the understanding and treatment of diseases. However, the representation of pathophysiological explanations in the management of clinical cases differs for various levels of medical expertise and different theories have been proposed to explain this phenomenon. The present study investigated for the first time how biomedical knowledge is used in clinical reasoning in dental medicine.

MATERIALS AND METHODS

In an experimental study 20 experts in the field of Periodontology and 61 students of different levels of training produced written pathophysiological explanations after having studied three different clinical cases. By comparing the written protocols to a visualised expert-made 'canonical' explanation the concepts used in the pathophysiological explanation were counted and classified as well as the links between concepts.

RESULTS

The statistical analysis by MANOVA showed significant differences between third- and fourth-year students, students of intermediate expertise level (fifth-year) and experts for various parameters qualifying concepts or links of the written pathophysiological explanations. The participants of intermediate expertise level produced a high rate of concepts and links; however, characteristic findings for knowledge encapsulation in the different levels of expertise were not evident. The analysis showed that the design of the clinical cases and of the canonical explanations significantly influenced the outcomes.

CONCLUSION

The present study demonstrated the pathophysiological representations of clinical cases in dental students and experts to be different from other medical disciplines. It could be assumed that this observation is based on different contents for teaching of practical skills and diagnostic procedures in dental compared with medical education.

Influence of perceived difficulty of cases on physicians' diagnostic reasoning

PURPOSE

While diagnosing problems, physicians frequently switch from nonanalytical to reflective reasoning. The conditions inducing doctors to reflect are largely unknown. The authors investigated whether a shift to reflection occurs when physicians perceive a case as problematic, and its effects on diagnostic accuracy.

METHOD

The authors conducted two within-subjects experiments in Brazilian teaching hospitals in 2007. In Experiment 1, 20 medical residents diagnosed the same 10 clinical cases under two experimental conditions: a nonproblematic versus a problematic context. (The latter was created by informing participants that other physicians failed to diagnose the case previously.) In addition, participants judged whether a set of medical concepts were related to the case, and response time was measured. In Experiment 2, 18 residents diagnosed two cases while thinking aloud. The authors hypothesized that a case perceived as problematic would trigger reflection, leading to higher diagnostic accuracy, lower response times for recognizing concepts (Experiment 1), more time for diagnosing, and more elaborate think-aloud protocols (Experiment 2).

RESULTS

Experiment 1: Accuracy of diagnosis was significantly higher within the problematic context, and participants were faster in deciding whether concepts were related to the case. The same cases were evaluated as more complex and less frequently seen. Experiment 2: Time spent on diagnosis, memory for case findings, and inferences derived from the cases were significantly higher within the problematic context.

CONCLUSIONS

A context perceived as problematic induced reflection in the participating clinicians, as indicated by lower response times, more time spent on diagnosis, and more elaborate protocols. Reflective reasoning comprised more careful analysis of findings and alternative diagnoses, and increased diagnostic accuracy.

How expertise develops in medicine: knowledge encapsulation and illness script formation

CONTEXT

For over 30 years, research has focused on the question of how knowledge is organised in the doctor's mind. The development of encapsulated knowledge, followed by the formation of illness scripts, may both be considered as important stages in the development of medical expertise.

METHODS

This paper reviews research on the knowledge encapsulation and illness script hypotheses since their initial formulation. Findings in support of these views of expertise development are reported and conflicting data are discussed.

RESULTS

A great deal of empirical data have been collected over the years to investigate the view that, through clinical experiences, biomedical knowledge becomes encapsulated and eventually integrated into illness scripts. The findings of most studies, which have used various techniques to probe the ways by which students and doctors mentally represent clinical cases, are in line with this view of expertise development. However, there is still debate concerning the role of biomedical knowledge in clinical case processing.

CONCLUSIONS

To facilitate the development of expertise in medical school, it is important to teach the basic sciences in a clinical context, and to introduce patient problems early in the curriculum in order to support the processes of encapsulation and illness script formation. In addition, during clerkships ample time should be devoted to enabling reflection on patient problems with peers and expert doctors.

Clinical case processing: a diagnostic versus a management focus

CONTEXT

Most studies on medical expertise research have focused on diagnostic performance, whereas patient management has been largely ignored. According to knowledge encapsulation theory, applying encapsulated knowledge is a characteristic of expert doctors' diagnostic reasoning, but it is unclear whether or not encapsulated knowledge also plays a prominent role when processing a clinical case with a management focus.

METHODS

The participants were 40 medical students (20 in Year 4 and 20 in Year 6) and 20 expert doctors (internists). Participants were asked to study the cases with either a diagnostic (Dx) or a management (Mx) focus. Subsequently, participants were asked to write down what they remembered from the case.

RESULTS

In both conditions, experts recalled fewer propositions and used more high-level inferences than medical students. Furthermore, they processed the cases faster and more accurately than medical students, but no significant difference between Mx and Dx conditions was found. Year 4 students also showed no significant differences in recall and processing speed between conditions. By contrast, Year 6 students recalled more in a Dx than in an Mx condition, but there was no significant difference in processing speed between conditions.

CONCLUSIONS

In both conditions, findings indicate that the experts' and Year 4 students' performance was not affected by processing focus. The fact that only Year 6 students were affected by processing focus might be explained by the assumption that their diagnostic knowledge and management knowledge are not fully integrated yet, a process that has already taken place in the expert's knowledge structure.

Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning

CONTEXT

Two modes of case processing have been shown to underlie diagnostic judgements: analytical and non-analytical reasoning. An optimal form of clinical reasoning is suggested to combine both modes. Conditions leading doctors to shift from the usual mode of non-analytical reasoning to reflective reasoning have not been identified. This paper reports a study aimed at exploring these conditions by investigating the effects of ambiguity of clinical cases on clinical reasoning.

METHODS

Participants were 16 internal medicine residents in the Brazilian state of Ceará. They were asked to diagnose 20 clinical cases and recall case information. The independent variable was the degree of ambiguity of clinical cases, with 2 levels: straightforward (i.e. non-ambiguous) and ambiguous. Dependent variables were processing time, diagnostic accuracy and proposition per category recalled. Data were analysed using a repeated measures design.

RESULTS

Participants processed straightforward cases faster and more accurately than ambiguous ones. The proportion of text propositions recalled was significantly lower (t[15] = 2.29, P = 0.037) in ambiguous cases, and an interaction effect between case version and proposition category was also found (F[5, 75] = 4.52, P = 0.001, d = 0.232, observed power = 0.962). Furthermore, participants recalled significantly more literal propositions from the ambiguous cases than from the straightforward cases (t[15] = 2.28, P = 0.037).

CONCLUSIONS

Ambiguity of clinical cases was shown to lead residents to switch from automatic to reflective reasoning, as indicated by longer processing time, and more literal propositions recalled in ambiguous cases.

The role of biomedical knowledge in clinical reasoning: a lexical decision study

PURPOSE

To investigate the role of biomedical and diagnostic inferences in clinical reasoning of advanced medical students and experienced family physicians using a lexical decision task.

METHOD

In 2002, 15 family physicians and 20 fourth-year medical students at Maastricht University medical school in The Netherlands were instructed to carefully study 60 short clinical texts consisting of signs and symptoms associated with a particular disease. Participants read the texts on a computer screen and responded using a computer keyboard. Each text was followed by a target item (i.e., biomedical item, diagnostic item, or a nonword). Participants had to decide as quickly and accurately as possible whether the presented target item was a word or a nonword. For both groups, mean response time and mean error rate for all levels of item type were analyzed.

RESULTS

Findings indicate that both physicians and medical students judged diagnostic target items faster and more accurately than biomedical target items. However, physicians were considerably faster than were students on judging biomedical and diagnostic target items.

CONCLUSIONS

These findings are largely in line with knowledge encapsulation in that biomedical knowledge still plays a prominent role in the physician's clinical reasoning.

The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach

PURPOSE

To examine four theories on the role of basic science knowledge and clinical knowledge in diagnostic reasoning.

METHOD

In 2000-01, the authors tested the basic science and clinical knowledge and diagnostic performances of 59 family physicians and 184 second- to sixth-year medical students at Maastricht University, The Netherlands. Structural equation modeling was used to analyze the data. Four theoretical models were tested. In the first model only basic science knowledge is involved in diagnostic reasoning; in the second model only clinical knowledge is related to diagnostic reasoning; in the third model, clinical knowledge is related to diagnostic reasoning, but basic science knowledge is integrated in clinical knowledge; and in the fourth model, both basic science knowledge and clinical knowledge independently influence diagnostic reasoning.

RESULTS

Forty-four (75%) of the family physicians and 184 (100%) of the students responded. The results indicated that the third model, which is based on the knowledge encapsulation theory, provided the best fit to the data, whereas the models that had directly related basic science knowledge with diagnostic performance did not fit the data adequately.

CONCLUSION

The results generally supported the third model by Schmidt and Boshuizen of knowledge encapsulation theory suggesting that basic science knowledge is activated in expert diagnostic reasoning through its relation with clinical knowledge.

The role of encapsulated knowledge in clinical case representations of medical students and family doctors

BACKGROUND

Previous studies on the development of medical expertise, predominantly using measures of free recall and pathophysiological explanations, have shown ambiguous results concerning the relationship between expertise level and encapsulated knowledge.

PURPOSE

To investigate differences in clinical case representations by medical students and family doctors. In particular, the role of encapsulated knowledge in clinical case representations was investigated.

METHODS

Year 2 (n = 15) and Year 4 (n = 15) medical students and family doctors (n = 15) were instructed to study carefully 2 case descriptions associated with a particular disease. After each case description participants were asked to provide a diagnosis. Subsequently, they judged whether or not a target item presented on a computer screen was related to the case description. Target items consisted of literally stated signs and symptoms, inferred encapsulated items and filler items.

RESULTS

Family doctors provided more accurate diagnoses than Year 2 and Year 4 medical students. Furthermore, family doctors were faster and made fewer errors in judging the relatedness of all item types than Year 2 and 4 medical students. In particular, family doctors showed their best performance on the encapsulated items.

CONCLUSIONS

The present study showed that encapsulated knowledge becomes increasingly more prominent as expertise develops. For experienced doctors, encapsulated concepts function as the most important building blocks of clinical case representations.

Clinical case processing by medical experts and subexperts

Medical specialists, diagnosing cases within their domain of expertise, do not rely on intentional causal reasoning, in which they use explicit principles or rules of their domain. Rather, their reasoning has become an automatic process using schema-based knowledge. However, the difference between diagnoses made by medical specialists and diagnoses made by nonspecialists (i.e., subexperts) is unclear. In the present study, cardiologists (the experts), pulmonologists (the subexperts), and advanced medical students evaluated two clinical cases within the domain of cardiology. The cases were divided into four components (i.e., patient's history, physical examination, laboratory data, and additional findings) that were sequentially presented. The task was to study, diagnose, and recall the segmented clinical case description. It was expected that the subexperts and students, as a result of their lack of specific expertise, would focus on different case components than the experts would. However, results indicated that the main difference between experts and subexperts (and to a lesser extent, students) was not a difference in emphasis on case components, but the speed and accuracy of processing these case components.