Learning and Memory in Medical Training

Biomedical and Encapsulated Knowledge

During their first years in medical school, students acquire a large body of knowledge concerning the basic sciences. This type of knowledge, which will further be referred to as biomedical knowledge, entails subjects such as physiology, anatomy, microbiology, and pathology. Biomedical knowledge will develop into rich and elaborate causal networks that explain the causes and consequences of disease in terms of general underlying processes. Most medical curricula are divided into preclinical years, which mainly focus on biomedical knowledge, and a clinical program consisting of clinical courses and practicals. During the clinical years, students are often for the first time confronted with real patients, and they can witness the impact of a disease on a patient's life. This clinical experience also provides students with the opportunity to establish links with their elaborate biomedical knowledge.

Encapsulated Knowledge

This integration of biomedical and clinical knowledge is most clearly established by Schmidt and Boshuizen's theory of knowledge encapsulation. It is assumed that through extensive and repeated application of biomedical knowledge and through confrontation with clinical problems, the students' elaborate biomedical networks of knowledge will eventually be subsumed under higher-level concepts with the same explanatory power. In other words, experienced physicians who are asked to explain the signs and symptoms of a patient will most likely use much more encapsulated concepts in their explanations than a less-experienced medical student.

For instance, if a student is required to explain the shortness of breath of a patient with a heart condition, her or his response may look like this: “If the ability of the heart to pump the blood forward from the left side is diminished, the body does not receive enough oxygen. The pressure in the veins of the lung increases and may result in fluid accumulation in the lung, leading to shortness of breath.” An experienced physician, on the other hand, will refrain from this detailed, causal explanation and may respond by saying that shortness of breath in this case results from left-sided heart failure. This does not imply, however, that the physician does not know the detailed explanation provided by the student—studies have shown that physicians can easily produce the student's explanation if the task requires it—but it does imply that the concept of “left-sided heart failure” incorporates or encapsulates the detailed, causal description.

Similar results were found in clinical case studies using free recall. In these studies, using the so-called clinical case paradigm, participants of different levels of expertise were required to study a clinical case description, provide a diagnosis, and write down everything they could remember from the case (in a free order). Each case reported some contextual information, the complaint, findings from history-taking and physical examination, relevant laboratory data, and some additional findings (e.g., X-rays, ECGs). What many of these studies have shown is that advanced medical students not only remembered more from the case description than less-advanced students; they also remembered more from the case than experienced physicians. This phenomenon has been dubbed the intermediate effect. That is, the participants from an intermediate level of expertise remembered most details from the case. In line with the knowledge encapsulation theory, physicians will refrain from a detailed recall of all the facts and findings in a clinical case. They will instead use higher-level concepts that incorporate or summarize much of the information provided in the case. For example, [Page 667]consider the following fragment from a clinical case

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