To determine whether medical students entering the first year of clerkships perceive an expanded role for their biomedical science knowledge beyond its role in clinical reasoning and decision making, we asked students at the beginning of their family and community medicine and pediatric and adolescent medicine clerkship to reflect on how biomedical science knowledge was relevant to clinical medicine. Open coding identified ten codes that were synthesized into four themes that described medical students’ perceptions: knowledge to practice medicine, lifelong learning, physician-patient relationship, and learner perception of self (Table 1). We next examined students’ responses to prompts in the mid-clerkship reflective writing assignment to identify support for the codes and themes. Specifically, students were asked to: 1) select and briefly describe a patient encounter, 2) think about the patient’s illness or disease process through a basic science lens by accessing, exploring, and extending their biomedical science knowledge, 3) reflect on how the new learning impacted the care of their patient, and 4) consider how this process may impact their future clinical practice, and reevaluate their perception of the relevance of biomedical science knowledge to clinical medicine. Below, we describe the codes and themes and provide representative student quotes.
Theme 1: Knowledge to practice medicine
This theme developed from the clustering of four codes: diagnosis, patient management, tolerance of ambiguity, and patient safety (Table 1), and addresses the use of biomedical science knowledge to support clinical reasoning and to justify clinical decisions.
Code 1a: Diagnosis
This code included many of the physician tasks required to formulate a diagnosis (Table 2) and had an overall frequency of 30% (Table 3).
Pre-clerkship assignment: “Biomedical science knowledge is relevant to clinical medicine because it allows for a deeper understanding of the disease processes occurring in patients and helps us make more informed decisions for their care. If we have a firm grasp of physiology and pathology, we can conceptualize what is “normal” in our patients and how that normal has been interrupted by disease.” (4T).
Mid-clerkship assignment: “By thinking about basic science and what mechanisms could be causing the patient’s symptoms, I was better able to come up with possible differential diagnoses.” (1Y).
Code 1b: Patient management
This code relates to various physician tasks required for patient management (Table 2) and had the highest overall frequency (72%) (Table 3).
Pre-clerkship assignment: “… understanding the science behind our actions allows us to anticipate the outcomes of our treatment… Without the basic science knowledge to guide our practice, we would just blindly follow clinical guidelines… [it is] important to understand the science behind those guidelines so that we can adjust accordingly, and better treat patients that might not fit in to a defined set of rules.” (3P).
Mid-clerkship assignment: “On initial glance, a rash, abdominal pain, and hypertension seem seemingly unrelated. However, the basic science understanding of Henoch-shönlein purpura helped pull all of these components together. The process of reading about Henoch-shönlein purpura was fundamental to providing the best care possible for our patient.” (1B).
Code 1c: Tolerance of ambiguity
Tolerance of ambiguity captured the concept that patients and disease processes are complex, and management requires the application and integration of basic science and clinical science knowledge to provide optimal care (Table 2). This code had an overall frequency of 23% (Table 3).
Pre-clerkship assignment: “… clinical medicine is full of patterns and puzzles. Three patients who all come in with a cough can have extremely diverse disease processes and therefore require unique treatments… a thorough history and physical must be combined with basic science knowledge to accurately diagnose a patient.” (1B).
Mid-clerkship assignment: “Incorporating basic science objectives when treating patients allows you to modify your care for situations when treating patients that are not “traditional” patients. You can better adjust your care when patients have multiple active disease processes and medications with potential interactions.” (2W).
Code 1d: Patient safety
This final code within theme 1 focused on the use of biomedical science knowledge to prevent medical errors (Table 2) and had a frequency of 17% (Table 3).
Pre-clerkship assignment: “Without biomedical science knowledge, it is possible to misdiagnose patients or continue to make recommendations or prescribe treatments that, at best, don’t work and, at worst, do more harm than good.” (2S).
Mid-clerkship assignment: “… this deeper understanding was critical to ensuring that we were drawing the appropriate labs/imaging and monitoring the necessary vitals to prevent or address any complication.” (1B).
Finally, three students presented minority arguments that disagreed with the theme “knowledge to practice medicine”, and expressed views that biomedical science knowledge has no role in some physician skills, including communication and interpersonal skills:
“… there is very little correlation between biomedical science knowledge and how great someone might be in the clinic... Yes, the baseline knowledge might be important, but clinical knowledge has more to do with your ability to talk to a patient like a human being and help them feel better.” (1R).
Theme 2: Lifelong learning
This second theme addressed the need for physicians to continue to expand their biomedical science knowledge throughout their careers. This theme developed from a single code: continue learning throughout practice to understand and apply advances in science and medicine (i.e., evidence-based medicine) (Table 1).
Code 2a: Continue learning throughout practice
This code reflected the need for physicians to continue to acquire new knowledge by engaging with the research literature to understand and apply advances in science and medicine (Table 2). This code had an overall frequency of 55% (Table 3).
Pre-clerkship assignment: “As new research emerges within the medical field, clinicians must rely on the knowledge they gained in medical school to process and understand the literature... Without [a] solid foundation of biomedical education, physicians would not be capable of synthesizing and comprehending the new data.” (4B).
Mid-clerkship assignment: “As I continue in my medical education, I believe that tying basic science concepts into my clinical practice will not only help me to better understand disease processes that I encounter, but it will also allow me to better adapt to new management and treatment approaches, because I will understand the underlying processes being targeted.” (4C).
Theme 3: Physician-patient relationship
The third theme of physician-patient relationship described the use of biomedical science knowledge to educate and empower patients. This theme developed from the clustering of three codes: educate patients, empower patients, and develop patient trust (Table 1).
Code 3a: Educate patients
The ability to educate patients requires the use of biomedical science knowledge to answer patient questions, respond to patient concerns, dispel incorrect medical information, destigmatize misconceptions of disease, and explain disease and treatments in terms that are understandable to patients (Table 2). This code had an overall frequency of 28% (Table 3).
Pre-clerkship assignment: “… understanding the basic science behind disease allows the physician to better explain to patients what is happening to them. This leads to a better physician-patient relationship.” (1Y).
Mid-clerkship assignment: “Ultimately, the process of viewing a patient through a basic science lens helps to educate oneself which, in turn, translates into an opportunity to educate the families and [the] rest of the medical team on rounds or presentations.” (1P).
Code 3b: Empower patients
Students recognized the use of biomedical science knowledge to empower patients to become actively involved in their own healthcare (Table 2) and had a frequency of 19% (Table 3).
Pre-clerkship assignment: “A physician must have the knowledge, and the ability to accurately inform patients of their options, allowing the patient to make an informed decision about the course they choose to take, as well as the potential ramifications of that choice such as drug side effects, and the consequences of not taking a particular medication.” (4D).
Mid-clerkship assignment: “This not only equips me to better manage those conditions, but also to build better relationships with my patients. Furthermore, in educating patients about their conditions, they become more invested in their health and are better able to manage their medical problems as well.” (3P).
Code 3c: Develop patient trust
This code captured the concept that patients (and society) expect physicians to have a wealth of biomedical science knowledge, and that this knowledge base contributes to establishing the trust of patients and providing compassionate care (Table 2). This code had an overall frequency of 13% (Table 3).
Pre-clerkship assignment: “Patients often want to know what is happening when they suffer from a disease and having the knowledge to explain this to them increases rapport and confirms the trust that they put in the physician. Patients want to feel like they are being cared for by an expert, and there is no better way to show expertise than to describe in detail what is happening, why it is happening, and what we can do to treat it effectively.” (4T).
Mid-clerkship assignment: “Getting a new diagnosis can be confusing and overwhelming, and it can be reassuring when the doctor explains things. Even if he or she does not know exactly what is wrong, the effort to explain things on a level that the patient can understand can build rapport and be very important.” (2C).
Theme 4: Learner perception of self
The final theme, learner perception of self, captured how biomedical science knowledge contributes to the development of a professional identity. This theme developed from the clustering of two codes: develop confidence and competence as a physician and transition from layperson to physician (Table 1).
Code 4a: Develop confidence and competence as a physician
This code was interpreted from student perceptions that biomedical science knowledge contributes to the development of confidence and competence as a physician and provides a common language in which to engage with colleagues and other members of the healthcare team (Table 2). This code had the lowest frequency (8%) (Table 3).
Pre-clerkship assignment: “When we understand why a certain treatment works, not just that it works, we develop true, long-lasting clinical knowledge that allows us to treat our patients with confidence. What’s more, the biomedical sciences are a language that we use to communicate with each other and with our research science colleagues.” (4S).
Mid-clerkship assignment: “The basic science preparation and reading really helped elevate the level of discussion when presenting to the attending.” (1B).
Code 4b: Transition from layperson to physician
This code captured the idea that biomedical science knowledge is expected of oneself, one’s colleagues, and by one’s patients. Students perceived that the application of biomedical science knowledge in a clinical context forms the basis of their emerging identity as a physician (Table 2). This code had an overall frequency of 13% (Table 3).
Pre-clerkship assignment: “… if our knowledge were limited to asking a list of questions, identifying abnormalities, and prescribing the correct medications off a list of protocols then we would simply be technicians. Those skills can be programmed into a computer algorithm that can diagnose disease and treat patients. The value in doctors is that we are both clinicians and scientists.” (2F).
Mid-clerkship assignment: “And I think that must be a part of medical practice and education, to push those around us to continually fill the gaps in our knowledge, and remember the importance of the basics in leading to what we do.” (1A).
Students’ learning trajectory
In analyzing the students’ essays in response to the pre-clerkship assignment prompt, we observed that the majority of responses reflected simplistic application of their biomedical science knowledge.
“Knowing that a drug only works when functioning beta cells are present allows me to recognize that these medications would not work for a type I diabetic because type 1 diabetics no longer have functioning beta cells.” (1T).
Students’ responses reflecting a more sophisticated application of biomedical science knowledge were far fewer:
“Rather than memorizing what causes edema, I was able to use my basic science knowledge to not only know what might be causing it but why. This also helped me understand the treatment. For example, in the case of congestive heart failure, I knew that the cause of edema was increased hydrostatic pressure and the way to relieve that is to get rid of fluid. Therefore, I knew that using a diuretic in this case would help this person’s worsening edema.” (2A).