The basic sciences aspreparation for clinicallearning

To an experienced clinicianworking in a medical school,supervising a basic biosci-

ence examination is not nearly asstressful as sitting the examitself. But when a series of can-didates ask for clarification ofquestions that appear to make nosense, the stress levels begin torise.

Just how much basic sciencedoes a medical student need inorder to become a good doctor?The thought crowded unbiddeninto my mind as I tried to help acandidate interpret a multiple-choice question that venturedinto the arcane realms of bio-chemistry: ground untravelled byme for many decades. The knowl-edge required to answer thequestion was either so deeplyburied in my cerebral cortex as tobe irretrievable, or it had neverbeen acquired in the first place.Certainly, its absence had neverbeen a bother in the clinic.

In his seminal and oft-quotedreport of 1910, Flexner declared:‘We have concluded that a two-year college training, in which thesciences are ‘‘featured’’, is theminimum basis upon which mod-ern medicine can be successfullytaught’.1 Since then, medicalcourses have typically had a pre-clinical phase in which the basicsciences are studied, followed bya clinical phase of similar length.The introduction of early clinicalskills teaching, the integration ofthe basic sciences to form courseswith a patent focus on healthpractice and the rise of problem-based learning have all combinedto blur these boundaries; but it isstill possible to detect a distinct‘clunk’ as the student moves fromthe preclinical phase to the clin-ical phase.

From the clinical teacher’spoint of view, the expectation isthat students delivered by theuniversity to their clinical place-

ments will arrive with an ade-quate grounding in thebiosciences. This usually meansenough knowledge of anatomy toknow which structures might beimplicated in an acute presenta-tion, enough physiology and bio-chemistry to understand how thebody actually works, and enoughmicrobiology and pathology tofigure out why things have gonewrong (as well as enough phar-macology to understand howdrugs might help to fix the prob-lem). Teaching clinical medicinewithout a firm bioscience foun-dation upon which to build is afraught experience, as is having astudent who is well versed in thelaboratory sciences but bereft ofthe medical humanities andbehavioural sciences that so eas-ily lose their identity in an inte-grated curriculum.

Some might argue that thediscipline involved in studyingthe basic sciences in depth helps

Editorial

� Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 1–2 1

to develop the intellectual rigourrequired for effective clinical rea-soning, in the same way thatlearning Latin was supposed to‘train the brain’.2 Memorising thesteps involved in Krebs’ tricar-boxylic acid cycle might just helpbuild the capacity to jugglemultiple diagnostic hypotheses inthe consulting rooms, althoughthis is extremely unlikely if theknowledge is unrelated to theclinical task. As recently shown byGoldszmidt and colleagues,understanding the basic sciencebehind physical signs (in theirexample, the physics of soundtravelling through the lung) helpsto interpret their clinical signifi-cance.3 Others have shown thatunderstanding the basic causalmechanisms of disease does helpstudents recall information.4,5 Ofcourse, the key factor is that thescience content is directly rele-vant to the clinical condition, notabstract from it, and that stu-dents can use this firm foundationto launch new hypotheses

about the causes of a patient’spresentation.

A really well designed preclin-ical curriculum is a delicate blendof carefully chosen ingredientsthat provides students with ameal that is both flavoursome andnutritious. To stretch this culinaryanalogy, these separate ingredi-ents should integrate so well thatthey fit together nicely whilemaintaining their distinct iden-tity. The students should feastupon a crisp tossed salad ratherthan upon homogenised slurry, sothat they arrive in their clinicalyears with a solid understandingof the biosciences under theirbelt.

Steve TrumbleEditor in Chief

REFERENCES

1. Flexner A. Medical education in the

United States and Canada. New York:

The Carnegie Foundation for the

Advancement of Teaching, Bulletin

Number Four, 1910. P: 26.

2. Thorndike EL. The influence of first

year Latin upon the ability to read

English. School Sociology

1923;17:165–168.

3. Goldszmidt M, Minda JP, Devantier

SL, Skye AL, Woods NN. Expanding

the basic science debate: the role of

physics knowledge in interpreting

clinical findings. Adv Health Sci

Educ Theory Pract. 2011 Oct 15.

[Epub ahead of print]

4. Woods NN, Neville AJ, Levinson AJ,

Howey EH, Oczkowski WJ, Norman

GR. The value of basic science in

clinical diagnosis. Acad Med. 2006

Oct;81(10 Suppl):S124–7.

5. Woods NN, Brooks LR, Norman GR. It

all makes sense: biomedical knowl-

edge, causal connections and mem-

ory in the novice diagnostician. Adv

Health Sci Educ Theory Pract. 2007

nov;12(4):405–15.

doi: 10.1111/j.1743-498X.2011.00532.x

2 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 1–2