The essential role of basic science in medical education: the perspective from psychology

Two lines of inquiry have examined how clinicians use basic science by asking them to think aloud as they read a clinical case.(f.2,3) Both studies concluded that clinicians rarely used basic science in developing an explanation. It should be noted that these conclusions were based on a very limited number of cases, and the clinician's goal was always diagnosis, not management. Still, it is likely that most practitioners most of the time need not invoke basic science explanations to understand a patient's problem. However, in relatively rare circumstances when things do not fit together, the clinician might go back to basic principles to reason it out. There is some evidence to support this hypothesis. [Patel VL] and associates(f.4) found that specialists operating outside their specialty (where presumably the solution was less likely to be forth-coming) were more likely to invoke basic science. Another study(f.5) suggested that specialists may use basic science concepts when working within their own specialty. In this study, nephrologists, second-year medicine residents and first-year family medicine residents were confronted with a series of 8 very difficult nephrology problems on paper and asked to "think aloud" as they reasoned their way through the problem. Diagnostic accuracy of the first-year residents was about 20%, of the second-year residents, it was about 50% and of the nephrologists, about 90%. More striking was that the process was very different in the 3 cohorts. The first-year residents seemed to have real difficulty generating hypotheses -- they had few diagnoses and ordered few tests. Second-year residents had the most hypotheses and ordered the most tests but were unable to reach a conclusion. Nephrologists knew what they were dealing with and ordered relatively few, targetted additional tests. More striking was that, whereas the first-year residents rarely thought about basic mechanisms, this was the modus operandi of the specialists. Returning to the main theme, I wish to review evidence from psychology that understanding contributes to learning. In brief, the perspective of psychology is that "people construct new knowledge and understanding based on what they already know and believe."(f.7) In a number of studies, [Brophy S Bransford JD] and colleagues(f.8) examined the effect of learning for understanding versus learning to remember. In one classic study, they showed 2 groups of students some text about learning to fly a kite. The te