Connecting Biochemistry Knowledge to Patient Care in the Clinical Workplace: Senior Medical Students’ Perceptions about Facilitators and Barriers

Abstract

Phenomenon: Medical students have difficulties applying knowledge about biomedical mechanisms learned before clerkships to patient care activities. Many studies frame this challenge as a problem of basic science knowledge transfer predominantly influenced by students’ individual cognitive processes. Social cognitive theory would support extending this framing to the interplay between the individual’s cognition, the environment, and their behaviors. This study investigates senior medical students’ experiences of biochemistry knowledge use during workplace learning and examines how their experiences were influenced by interactions with people and other elements of the clinical learning environment. Approach: The authors used a qualitative approach with a constructivist orientation. From September to November 2020 they conducted semi-structured interviews with 11 fourth-year medical students at one institution who had completed the pre-clerkship curriculum, core clinical clerkships, and the United States Medical Licensing Exam Step 1. The authors identified themes using thematic analysis. Findings: Participants reported that they infrequently used or connected to biochemistry knowledge in workplace patient care activities, yet all had examples of such connections that they found valuable to learning. Most participants felt the responsibility for making connections between biochemistry knowledge and activities in the clinical workplace should be shared between themselves and supervisors, but connections were often recognized and acted on only by the student. Connections that participants described prompted their effort to retrieve knowledge or fill a perceived learning gap. Participants identified multiple barriers and facilitators to connecting, including supervisors’ behaviors and perceived knowledge, and “patients seen” in clerkships. Participants also reported learning biochemistry during USMLE Step 1 study that did not connect to patient care activities, underscoring a perception of disconnect. Insights: This study identifies specific personal, social, and physical environmental elements that influence students’ perceived use of biochemistry during patient care activities. Though these findings may be most significant for biochemistry, they likely extend to other basic science disciplines. Students’ self-directed efforts to connect to their biochemistry knowledge could be augmented by increased social support from clinical supervisors, which in turn likely requires faculty development. Opportunities for connection could be enhanced by embedding into the environment instructional strategies or technologies that build on known authentic connections between biochemistry and “patients seen” in clerkships. These efforts could strengthen student learning, improve clinical supervisors’ self-efficacy, and better inform curriculum design.

Keywords:

• Biochemistry
• basic science
• student perceptions
• workplace learning
• social learning

Introduction

Basic science knowledge plays a prominent role in undergraduate medical education.^1–3 This knowledge is thought to benefit learners’ and physicians’ development and retention of clinical knowledge and reasoning skills, prepare them to address novel and complex problems,^4–8 and be important for identity formation.⁹ Despite calls to support basic science knowledge learning beyond the pre-clerkship curriculum, clerkship students struggle to apply what they have learned in the classroom to problems in the clinical workplace.^10–12 This struggle has been described for anatomy^13,14 but has not been extensively explored with other basic science disciplines.

Students’ struggles to apply medical biochemistry in the workplace may be more pronounced than for other disciplines. While medical educators since Flexner have included biochemistry in the sciences deemed foundational to medical practice,¹ and a 2009 American Association of Medical Colleges (AAMC)/Howard Hughes Medical Institute (HHMI) report specified biochemistry competencies and learning objectives among those that medical students should demonstrate before receiving a degree,¹⁵ biochemistry has a reputation in medical education as a discipline that lacks relevance to clinical practice and is focused on rote memorization.^16,17 In addition, students rate biochemistry lowest on the AAMC Graduation Questionnaire in how well it prepares them for clerkships.¹⁸

Some researchers have framed learners’ struggle to apply basic science knowledge in clerkships as a problem of transfer, defined as the application of knowledge or skills learned in one context to solve new problems in another context.^19–21 This is often described as a cognitive problem, drawing on concepts such as memory, retrieval, schema and script development, and encapsulation as important factors in organizing knowledge that is oriented for and accessible during patient care.^22,23 This view holds that transfer of basic science knowledge to clinical practice depends on effective cognitive integration.²⁴ Studies in this area have inspired efforts in medical education to design and evaluate curricula that support cognitive integration, including work by biochemistry educators in collaboration with other basic science and clinical educators to design curricula that support deep learning of concepts in the service of clinical reasoning.^25,26 However, studies that formally demonstrate transfer of basic science knowledge to clinical reasoning are few,^27,28 and often focus on pre-clerkship classroom learning as assessed by written exams, limiting applicability of findings to learning and outcomes in the clinical workplace.²⁴ A limited number of studies that examine clerkship-level students’ and educators’ perceptions regarding transfer of basic science knowledge generally highlight deficits in our understanding of this aspect of learning.^13,14,29 Simultaneously, curriculum reform trends toward shortening pre-clerkship curricula to incorporate opportunities for earlier clinical immersion and longer clinical training. Biochemistry and other basic science educators are left with a multilayered challenge: how to make difficult decisions about how to fit basic science into a compressed pre-clerkship curriculum,³⁰ in the absence of robust understanding of how students integrate their basic science knowledge in the clinical workplace and how to best support this process.

Social learning theories would suggest that a disconnect in using basic science knowledge to solve patient care problems depends not only on individuals having cognitive schema in which well-organized concepts are linked to clinical features, but also on interactions with people and other elements of the workplace environment. Social cognitive theory is one such theory that recognizes that learning is influenced by dynamic and reciprocal interactions between factors that are personal (the individual’s knowledge, attitudes, perceptions, goals, values, and previous experiences), behavior (external responses and actions), and environment (the physical and social context in which learning occurs).³¹ Through the lens of social cognitive theory, transfer has been described as a phenomenon that is cognitive, but “depends on people believing that certain actions in new or different situations are socially acceptable and will be met with favorable outcomes.”^{32(p 135)} Consideration of the social and physical elements of the workplace learning environment, and how they may interact with personal factors to influence transfer of basic science knowledge could be informative. For example, modeling, a critical support for learning in social cognitive theory, has been identified as a clinical supervisor behavior that facilitates student basic and clinical science knowledge integration during clerkships.³³

Consistent with findings from a review of business, learning, and psychology literature that identified learner characteristics and the work environment as key influences on transfer,³⁴ Peters and colleagues identified personal and social influences on transfer of learning between classroom and the clinical workplace.³⁵ Authors identified three phases of transfer: 1) preparation for transfer in the classroom, 2) connecting back to classroom knowledge while in the clinical workplace, and 3) reflecting on transfer and continuing the process. The authors found that students’ and educators’ expectations about who held responsibility for transfer in each phase varied, and that students’ behaviors were influenced by these perceptions. Students who felt responsible for transfer initiated discussions with clinical teams, while students who felt supervisors were responsible depended on clinical supervisors for assignment of tasks, triggers for learning, and feedback. The authors concluded the study with recommendations that students and supervisors have conversations to discuss their conceptions of responsibility in order to optimize learning activities to best support individuals’ learning.

The purpose of our study is to understand senior medical students’ perceptions of how they connect to and use their biochemistry knowledge in the clinical workplace, and how social and other environmental components of the clinical workplace, along with personal factors, influence these connections. Faculty and curriculum development recommendations could emerge from this line of inquiry that improve student learning.

Methods

Setting

Our study is situated in the four-year medical school curriculum at the University of California, San Francisco (UCSF). The initial 18-month pre-clerkship phase of the curriculum includes classroom and clinical workplace-based components. Applied foundational knowledge in basic and clinical sciences, including biochemistry, is concentrated in the pre-clerkship classroom component and revisited in a classroom-based thread during a subsequent 14 months of core clerkships, which includes lecture and small group discussions on topics matched to clerkships. Workload varies considerably by clerkship and site; institutional policy dictates a cap on total work hours. Students take two months to study for United States Medical Licensing Exams (USMLE Steps 1 and 2) before entering the final phase of the curriculum in their fourth year. The UCSF Institutional Review Board (study 19-27617) approved this study.

Participants

In August 2020 we recruited study participants from UCSF students who matriculated in 2016 or 2017, had completed core clerkships, and would graduate in 2021. From this group of 146, we excluded four students who had not taken USMLE Step 1 and seven who had been interviewed in a pilot for this study. We aimed to recruit a sample of students with a range of pre-clerkship biochemistry scores similar to that of the class as a whole. (Pre-clerkship biochemistry scores are determined based on the total number of “meets expectations” scores on open-ended summative exam questions in the pre-clerkship curriculum.) Groups of 10-15 students received email invitations to participate voluntarily in the study and reminders 1-2 weeks later. We interviewed the first 11 students who responded after 67 students had been invited. We ended recruitment at that point, having met our goal of recruiting participants with a range of scores. Analysis of interview transcripts and identification of patterns in our data concurrent with recruitment informed this decision. Participants received a $25 electronic gift card.

Research design

We designed a qualitative study, choosing a flexible approach³⁶ aligned with our goal of broadly exploring student experiences. Our study used an interpretivist approach, acknowledging that our own experiences influence our data collection processes and interpretations, and a constructivist orientation, embracing that individuals construct their own understanding of reality.

Instrumentation

We developed a semi-structured interview guide that consisted of open-ended questions (Appendix 1) based on review of literature on student perspectives of basic science curriculum design, integration, and transfer,^5,9,14,37 with a focus on Peters and colleagues’ transfer framework.³⁵ We incorporated the authors’ concept of making connections between clinical decisions and classroom knowledge throughout our questions as a student activity that could indicate when transfer occurs. Data from a pilot study additionally guided development of questions and probes.³⁸ After interviews with two participants we added a probe regarding the description of making connections, and a question about responsibility for transfer. As these changes were minor, data from these participants were included in our analysis.

Data collection

From September through November 2020, SC, a trained research analyst, conducted all 11 interviews using Zoom (Zoom Video Communications, Inc., San Jose, CA).³⁹ TBF listened to audio recordings from the first two interviews to check the quality and provide feedback to SC. Interviews were between 45 and 60 minutes and were audio-recorded and transcribed verbatim.

Data analyses

We applied thematic analysis to the interview transcripts, seeking to understand a set of experiences across our data set.⁴⁰ We chose this method for its flexibility and alignment with aiming to generate descriptions and interpretations, but not develop theory.⁴¹ After reading transcripts from the first few interviews, TBF, SC, and BO’B developed an initial coding framework. Some codes were developed inductively, and others were informed by themes identified in a pilot study³⁸ and in other publications.³⁵ Two authors each applied initial codes to two transcripts (TBF and SC on one, TBF and BO’B on the other), then reconciled discrepancies to refine and achieve consensus on the final codebook. TBF applied codes to all remaining transcripts using Dedoose 8.3.41 (SocioCultural Research Consultants, LLC, Los Angeles, CA). BO’B and SC independently reviewed the remaining coded transcripts, then discussed differences until consensus was reached. We analyzed excerpts for each code to generate themes, which were examined for interconnectedness.

Reflexivity

Perspectives and roles of each research team member shaped the research process. All four authors identify as white cisgender women. TBF is responsible for medical biochemistry education in the UCSF curriculum, and active nationally in advancing educational practices in that field. Given TBF’s position could influence participants’ responses, SC, a research assistant, managed recruitment, conducted interviews, and emphasized that all perspectives and responses were welcome. TBF’s views on biochemistry education contributed to her analysis of participant responses; however, all analysis was conducted with input from other authors who work outside of biochemistry education. BO’B and MvdS are experienced medical education researchers at UCSF and University Medical Center Utrecht, respectively. SC is a trained research assistant, with a Masters in clinical speech therapy. The engagement of foundational science educators and medical education researchers helped in the development of a process grounded in multiple domains of research. Regular discussions, shared memos, and an audit trail allowed us to challenge one another’s assumptions and to continuously refine our analyses of the data. Presentations, discussions, and peer review outside of the research team from education scientists and clinical educators allowed us to check our interpretations.

Results

Eleven fourth-year medical students with a range of pre-clerkship biochemistry knowledge scores participated. We identified themes that characterize participants’ experiences in connecting their biochemistry knowledge to patient care activities during the clinical workplace phase of learning related to infrequency, value, and responsibility. We also identified thematic barriers and facilitators to making connections. A final theme addressed the Step 1 study period and its enhancement of a perception of disconnect. Themes and representative quotes appear in Table 1.

Table 1. Themes and exemplary quotes from students’ descriptions of connecting biochemistry knowledge to patient care during clinical workplace learning.

Experience of connecting
Theme	Exemplar quotes
Infrequency	I think the biochemistry connection was just a little bit harder to make because it happened so far and few between. (#3) I just don’t really see it [biochemistry] coming up a lot. (#10) So, I honestly used biochemistry less than I had thought I would in my clerkships. (#9)
Connections have value inform patient care decision enhance communication with patients be a good doctor, prevent harm	So this was a patient who was brought into the hospital by his family because he had been altered for a number of days and wasn’t as responsive and lethargic. And then I think fairly quickly on the initial set of labs his blood sugars were in the 500 s or 600 s. And that’s sort of when I immediately sort of thinking about, "Well, I’ve heard about this before." … And so immediately I started thinking about DKA, which is a subject we spent a lot of time talking about in class, but then it sort of speaking with my intern, it was, "Well, this isn’t quite a DKA picture, but this is a sort of another complication of profound hyperglycemia in patients with diabetes." I was, "I know about DKA but I don’t quite know what this is because it doesn’t fit all the check boxes that I know about that." And then being encouraged to kind of read up on hyperosmolar nonketotic coma and be able to present that data to the team the next day…I will say that having made that connection and having had that assistance from the intern that led me to read up on that, is what really informed the assessment and plan I was able to formulate. I felt that I needed to understand as much of the underlying pathophysiology as possible because the patient really was asking, "Why is this syndrome happening to me?" And it is, for her, Wernicke encephalopathy to have been that severe, I think with this neuropathy and also tinnitus in her case. And I was really thinking about what could an underlying vitamin deficiency mean to explain, to be a unifying diagnosis for her. (#1) I think it’s valuable because I don’t think I will ever forget to give potassium to a patient who has either diabetic ketoacidosis or hyperosmolar, hyperglycemic state. I think in more just knowing the biochemistry behind the insulin has more cemented that knowledge. Now, it’s not just before, when I was just studying for shelves, and be like I just need to memorize facts and have them in. I have the reasoning behind it. And from that, I remember why it’s important to give potassium. I think it more helped cement the learning. It’s not something that I think I’ll forget anytime soon. Because now, I’ve seen it twice. That’s more stuck in my mind now. (#10)
Responsibility for connecting ideally shared between student and supervisors students take responsibility to act	I think that it’s always a shared responsibility. As a learner in this type of profession and environment, I think you have to take a lot of responsibility for your own learning. I personally do that to a greater or lesser degree, depending on my motivation on any given day. But certainly the more that you sort of seize the day and say, "I have some downtime here, or this is a relatively straightforward patient, but what can I do to get more out of this?" I think this sort of self-directed learning is obviously a big responsibility of ours, but having said that, that a good teacher or a preceptor in the clinical environment will sort of try and assess pretty quickly where their learner is at, and then figure out how to push them just a little bit past that boundary. That’s what my best preceptors did. (#6) …what’s important is that I’m familiar, that I did know it at some point, and that I know where to go back and remember it again. I would say that is how it helped me is that it gave me that first pass learning, which kind of set me up to be able to learn it ever better the next time…. . That was really what kind of drove me to look things up, and to ask questions, and to make those connections. That’s actually a good point that you brought up that I forgot that I said is that I … Wanting to be a good physician and an effective resident was a motivator in all those decisions and thought processes…. . I think sometimes I did, and then sometimes I just let it go. Because if it wasn’t that pertinent to what my patients were … But if it was something that I had to look it up, I think, for my own patient, then yeah, I would. (#3)
Barriers to connecting
Theme	Exemplar quotes
Supervisors’ behaviors that indicate discomfort, disinterest, or lack of biochemistry knowledge	I do think largely a lot of preceptors are not very comfortable with the biochemistry. So I think the general trend is to sort of lean away from the basic science in the clinical environment. So, for instance, for DKA, they would be like, "Oh, what do we measure in the blood? What do we measure in the urine to help us track DKA?" And they would say, "Oh, keto acids." But no one would really sort of go a step further to say why are keto acids building up. … I think on one hand, if it’s not clinically relevant to treating the patient, I can understand why an attending would say, "This is not that important to talk about right now." But I do think that attending and resident comfort with basic science directly translates into how much you can make those connections on rotations. (#7) They’re [attendings] more just saying like, "Oh, I just don’t remember. I’m so sorry. If anybody, you would know." I think that kind of prevented me from asking more questions… even maybe less nitty-gritty concepts that I wanted to ask, I would get a response like that. It almost even felt silly asking it. (#3)
“Patients seen” don’t have natural biochemistry connections	I had three clerkships before I went on my long research year and probably forgot most of my biochemistry knowledge. Those are anesthesia, dermatology, and radiology. In anesthesia, you hardly use any biochemistry because it’s all about physiology and pharmacology. Radiology, you’re not really thinking so much about biochemistry because you’re looking at imaging features and clinical history to guide what’s happening. And for dermatology, …biochemistry isn’t as relevant for dermatology diagnosis, except that nutritional deficiencies can cause rashes, in my mind. (#1)
Prioritization of patient care	…your learning necessarily has to be secondary to patient care. Because that’s what is very pressing and sometimes depending on the acuity of patients or severity of illness, but there’s just not a lot of space and reasonably, so for you to be asking questions or, "Let’s talk about this in depth." …And I felt sometimes if the services were really busy or if there was a generally high collective stress level, because patients were really sick, it didn’t feel a good time to pose those questions to the team. And that could kind of be a tricky space to navigate. (#5)
Facilitators to connecting
Theme	Exemplar quotes
Questions and tasks from supervisors	When my resident did all the management, and then she asked me about it, I was like, "Oh yeah, we have to give IV fluids…We’ve got to give insulin. We’ve got to give potassium." And then she asked me, "Oh, why do we give potassium?" And then, I blanked because I was like, "Oh …" That was like the biochemistry piece, "There’s a reason, I just don’t remember the reason why." And then she explained it to me, "When we give insulin, we cause a shift of potassium… hypokalemia has its own subset of problems. You could kill the patient…” (#10)
Tools, figures, notes from preclerkship curriculum	I was able to go back and look at my notes and then look up a little bit more about hyperosmolar, non ketotic coma. And then honestly I even think I pulled up the metabolic map copy that we had because I found that it would just really helpful in understanding well, which of these sort of sets of pathways is going to be kind of supercharged or upregulated in this patient and which of these are dampened and that map so nicely on to understanding a, the patient’s presentation and then why the management steps that we took were the management steps that we took. (#5)
“Patients seen” have obvious connections to biochemistry (particularly IM and peds)	I remember there’s like a couple cases that come to mind and these cases are on some clerkships more often than others. So for example, on my internal medicine clerkship, we had a patient who is in diabetic ketosis. There’s another patient who is in alcoholic withdrawal. And then another clerkship where this camp comes to mind is pediatrics with a lot of inborn errors of metabolism. (#2)
Step 1 study period
Theme	Exemplar quotes
Step 1 study emphasized disconnect to patient care	Essentially the way I thought about things was entirely different from how they expect you to learn and apply knowledge in step one. Step one I felt very heavy on pre-clinical knowledge. And by the time I ended my clerkships, I have not applied as much pre-clinical knowledge as I would’ve hoped. So I had to do a lot of recollection, a lot of refreshing my knowledge for pre-clinicals. And even for biochemistry I had to restudy and relearn a lot of the things that I’ve already learned. (#11)

Characterization of the experience of connecting biochemistry knowledge to patient care activities in the workplace

Infrequency

Participants universally reported infrequent direct connections to biochemistry knowledge during workplace learning.

I don’t think I’ve engaged with it [biochemistry] much in terms of my own clinical decision making. (#4)

Participants recognized indirect connections that they made to biochemistry knowledge, through other disciplines, especially pharmacology.

I think I connected it honestly through pharmacology a little bit more. So they would give certain medications and say, "Oh, this helps with GABA receptors," or something like that. And then, I remember[ed] hearing that in biochemistry… (#9)

Participants also noted that the distinction of biochemistry from other disciplines is not always clear.

I think it gets a little bit murky on deciding what is biochemistry, and what is pathology on a more cellular level. I was definitely told to read about cellular pathology, so if that is biochemistry, then yes. I was encouraged to learn biochemistry quite a bit. (#9)

Value

All participants recalled a few examples in which they made a direct connection to biochemistry knowledge during patient care activities that brought value to their learning. Participants described three main ways that connections provided value: by informing patient care decisions, enhancing communication with patients, and supporting participants in feeling like a “good doctor.”

Some participants specified how connections informed patient care decisions, for example those involving management.

…there are actually a number of clinical scenarios and management for patients that require a lot of biochemistry understanding. And then also an understanding of biochemistry helps to understand more deeply management and presentations for patients on clinical clerkships with a number of diseases. (#2)

Several participants noted that connections enhanced their ability to explain things to patients and their families.

I also think you owe it to patients to really understand things at the level of the pathway because I think it informs not only your understanding of the disease, but how you explain it to patients. (#8)

Others described how connections contributed to their ability to use clinical judgment and reasoning and prevent future harm, an expected part of their ability to “be a good doctor” (#2, #8).

… the big takeaway is that this direct connection of the basic science to the clinical setting, that has solidified a concept in biochemistry that I can now take with me. That was the whole goal. I want to be an effective physician and resident. Now I can really do that with this knowledge. (#3)

Responsibility

Most participants stated that both supervisors and students should share responsibility for making connections between biochemistry knowledge and patient care in the workplace.

I do think it’s helpful when an attending or a resident will point out being like, "Oh, by the way, there’s an interesting underlying biochemical pathway." And sometimes they’ll even say, "I don’t know what that is but it’s interesting and you can look it up." So I think when the medical student is able to make that connection, I think it’s much more rewarding because you’re like, "Oh, I remember this and it’s actually showing up." But I think sometimes… we’re just not able to fit those pieces together and I think in those situations when the resident or attending can help, I think that’s great. (#7)

A smaller number of participants felt students should be completely responsible for making connections.

I mean, it would be great if residents would call out those connections, but I don’t necessarily think it’s their responsibility. (#8)

The conception of shared responsibility played out in the ways that participants described their examples of connections. Most participants had examples in which they themselves recognized and acted on the connection by retrieving knowledge already present in their minds or their notes, or filling a gap regarding knowledge not learned well in the pre-clerkship phase. Some of these participants also had examples, though fewer, in which the supervisor pointed out the connection and/or engaged with the student in subsequent steps. After the recognition of a connection to biochemistry knowledge, most participants described taking action:

…you’ll oftentimes see a disease you either learned about or a disease you haven’t learned about but you maybe forgot the details of. And then you go back to your F1 notes and then you look through the disease, you go to UpToDate or other papers and you review the underlying process. (#7)

Some participants were able to easily connect to their biochemistry knowledge, while others worked harder to fill a knowledge gap, or struggled in making the connection in the first place.

I feel like there were a lot of times during third year when I was like, "Wait, is this an anticholinergic or is this a cholinergic picture. What’s happening here?" That drug that I just gave them, is that going to make them like a pinpoint pupil pig? Or is that going to make them like hot as it… I really had to think really, really hard to remember how the biochemistry behind all those neurotransmitters turned into a clinical picture and then like the pharmacology on top of it, it was like a struggle. (#6)

Many participants described willingness to put in effort to study and fill knowledge gaps, even if the connection was neither initiated nor explicitly discussed in the clinical learning environment. Participants described an acceptance of not remembering everything from the classroom, and expending effort to “spiral” or “take a second pass.”

I think that second round of going through things is oftentimes a lot more valuable for learning because I think the first time you learn it in F1, you just sort of hear a lot of diseases, a lot of pathways… I think when you actually see it in the clinical environment and you have to do a second review, I think that does help your learning a little bit more. So I do think that second review of having to go back and relearn is actually very important. (#7)

Barriers to connecting

Supervisor behaviors that indicate discomfort, disinterest in, or lack of biochemistry knowledge

Supervisor behaviors, which participants sometimes attributed to a perceived discomfort about biochemistry knowledge, presented social barriers to participants connections to biochemistry knowledge. Participants relayed that some of their supervisors displayed behaviors that indicated a negative reception to students’ attempts to connect to their biochemistry knowledge.

I had gone through the trouble of researching this pathway and was ready to present all of this back to the resident who had asked me to do it in the first place. She told me she didn’t care about it…It was demeaning, really. …They didn’t care about the specific biochemical pathway. What they cared about was what evidence, if any, there was to support whether or not to give this drug. (#1)

Participants also noted biochemistry was often missing in attendings’ and residents’ teaching; some could not recall the word “biochemistry” ever being used in the workplace environment.

I think nobody’s saying, "Oh, this is where your biochemistry is becoming useful." You can kind of forget that you’re engaging with it on that level… (#4)

Participants perceived that the absence of biochemistry from teaching indicated that some of their supervisors lacked knowledge about biochemistry as a topic.

…a lot of the attendings are just so far away from learning biochemistry that they might not know it as well as we do just because it’s been a while… (#2)

Participants also relayed that supervisors sometimes explicitly stated that they did not remember biochemistry.

I’ve had attending physicians straight up telling me, "I don’t really remember much about biochemistry." … they feel that they would not be able to teach me as much about biochemistry, or that I would probably know a lot more about biochemistry than they do at this point because it’s a lot closer to my training. (#11)

Many participants described deciding to avoid bringing up biochemistry, particularly in response to the perception of a social unwelcomeness to the topic. Participants did not want to create discomfort for supervisors, waste time, or be viewed negatively.

…you’re trying to impress people, not only with how smart you are, but also your personality and how you can function on a team. And I think that those social pressures often encourage you to not, to err on the side of, I mean, me personally, err on the side of like saying less and I’m trying not to sound like a know it all. (#2)

This participant further explained how they felt that their biochemistry knowledge, while often important to their learning, was not directly necessary for most clinical decision-making, and therefore could be ignored.

It definitely helps to understand the reasons why we do things and why diseases present in the way that they do, but it’s possible to get by without knowing them…You can choose to ignore it and just memorize that you should give this drug in this situation or that you should, that this disease always presents with this, but you might not, you’re not forced to make that connection the same way that you are with these other topics… (#2)

“Patients seen”

Participants noted that an understanding of biochemistry is relevant to a small subset of patient conditions, and that the likelihood of experiencing a patient condition that would prompt a connection to biochemistry in the workplace depended on the typical “patients seen” in that clerkship. As the set of medical conditions experienced by the clerkship’s patient population is discipline-specific, some clerkships may afford little or no possibility of a connection to biochemistry.

So I just never had an opportunity to see patients where those [biochemistry concepts] were, and we spent one day in the neonatal nursery…the whole year. So those were just biochemistry topics that I never had a chance for a repeat exposure to involving an actual patient. (#6)

Prioritization of patient care-focused learning

Participants described prioritization of learning core patient care activities (differential diagnosis, management, etc.) over in-depth learning of disease mechanisms, particularly in traditionally structured clerkships.

…we have to see 15 patients this morning. We have to take really good care of them all. Everybody can’t pick a topic that they want to hear everybody’s thoughts on. (#4)

Participants also noted ways that the pace of work on clerkships barred connections.

In the mornings on rounds, you’re quite often in a rush. So, having a student present for 15 minutes on the biochemistry of a certain disease is not going to be suited to having efficient rounds. (#4)

Facilitators to connecting

Supervisor questions and tasks that support connections to biochemistry knowledge

Participants reported that supervisor interactions were major contributors to connections. Being asked questions that went beyond an initial clinical decision (e.g., name the diagnosis, choose the drug) by asking for a rationale or a mechanism helped prompt connections, as did reading assignments and requests for presentations.

…the attending would ask me, "Okay, can you tell me the mechanism behind this drug?" I would say that’s probably the only time wherein I would reach back into my biochemistry learning and explain the mechanism behind each of these drugs. (#11)

Even participants who felt entirely responsible for making connections between biochemistry knowledge and patient care activities valued prompts from their supervisors.

I think if they helped us to spiral and to keep that toolbox fresh in our mind, I think that would be great. I don’t necessarily know if it’s their responsibility, but I think it would just help us commit it to long-term memory and help us be able to actually use it in clinical medicine. (#8)

Tools, figures, notes from preclerkship curriculum

Facilitators for connections included tools and visuals provided or created during the pre-clerkship phase of learning.

I can remember very vividly, as we were talking about it, …I had like a picture in my head of a learning tool we’d been given … the pathways by which lipids move around from different compartments in the body, right from the liver into the tissues, et cetera, and the different types of lipids. Then…superimposed on that in my head is a picture of the mechanisms of action of the different lipid lowering drugs…we were talking about how it was a good idea to offer this patient a statin. (#6)

“Patients seen”

Participants identified internal medicine and pediatrics clerkships most often as settings for connections, based on the conditions common to patients seen in these clerkships. Diabetes was the most often-cited condition that allowed for connections to biochemistry. Inborn errors of metabolism, disorders seen in pediatrics, was mentioned by multiple participants, though with the observation that even in pediatrics encountering patients with these conditions is very rare. Neuropharmacology, dyslipidemia, and alcohol use disorder were all cited by multiple participants. In general, participants acknowledged that connections arose for a small set of clinical conditions that are either common (e.g., diabetes) or fail to fit the typical pattern and require more knowledge to guide clinical reasoning.

Studying for USMLE step 1 and lack of connection

Most participants commented on how studying for USMLE Step 1 between core clerkships and sub-internships drove them to solidify and “put together” (#1) their biochemistry knowledge, but that much of that knowledge did not connect to patient care activities, reinforcing a perception of disconnect for biochemistry.

…there’s a lot of biochemistry on that test that we didn’t learn … because honestly it’s just not relevant clinically. And I think UCSF tried to teach us more clinically relevant biochemistry… (#2)

Some described this phase as challenging, having to learn biochemistry for the exam “from scratch” (#3) mainly by memorization, because for much of the tested content there was minimal formal exposure in the classroom and little reinforcement during the workplace phase of the curriculum.

I think I only ever looked up biochemistry for that one patient in neurology….For Step 1, that’s an entirely different question…I felt like I really had to relearn everything from almost ground zero. (#7)

Discussion

In this study, participants characterized experiences in the clinical workplace as relatively devoid of connections to biochemistry. The willingness of participants to act on connections once recognized, and the perception of shared responsibility for these connections with supervisors suggests that students make valuable connections to biochemistry in a setting with the right “patients seen.” These findings address a gap in research on how students connect discipline-specific basic science knowledge to patient care activities and add to the small number of studies that have examined medical student perceptions about their basic science training during the workplace phase of learning. The facilitators and barriers to making connections in the workplace learning environment were similar to those identified in a recent study examining student perceptions about integration of basic and clinical science.³³ Notably, although the focus of that study was perceived cognitive integration, interactions outside of the individual student’s cognition, similar to those described here, were deemed important. Below we discuss implications for future research and teaching efforts, with a focus on the clerkship phase, that speak to support of improved knowledge integration and transfer.

Participants reported finding value in their infrequent connections between biochemistry and their workplace patient care learning, supporting their ability to make patient care decisions, communicate with patients, and to “be a good doctor.” These findings align with those from Dickinson and colleagues, who observed that clerkship students’ connections to basic science knowledge during patient care supported their clinical reasoning, but also appear to contribute to adaptive expertise and identity formation.⁹ How frequent such connections should be remains unclear, especially given time constraints in the patient care learning environment. A minimal number of recognizable connections seems important in the context of curriculum revisions that trend toward minimization of pre-clerkship basic science curriculum time. Such curricular changes are associated with students devaluing basic science,⁴² and have led some to express concern about graduating students who may not be able to operationalize their basic science knowledge to meet the demands of precision medicine.^9,43,44 We propose that even if the overall number of connections that students make to biochemistry and other basic science knowledge in the setting of patient care is small, such opportunities should not be missed and considered deliberately in clerkship curriculum design and faculty development.

Our study supports previous findings that clinical supervisors are critical influences on the connections students make between their basic science knowledge and clinical workplace learning, through assignment of tasks (e.g., use of stimuli or triggers to help students check, refresh, or apply prior knowledge)³⁵ or explicit modeling of how basic science is used in clinical practice.³³ In many examples our study participants recognized and acted on connections alone, suggesting self-directedness and self-efficacy. However, absence of supervisor engagement with student connections may be problematic. Participants described welcoming and benefiting from interactions from their supervisors that helped with connections, which echoes students’ requests for help from supervisors noted in previous studies.^14,33 Without supervisor input students may not make correct associations between basic science knowledge and clinical features on their own, and may not make the connections at all.^45,46

Previous studies have suggested that modeling the ability to connect basic science concepts to clinical features during patient care could be an effective way to support knowledge integration and transfer, and have called for improved bedside-level support for student knowledge integration.^33,43 However, these studies describe faculty worries about being unprepared to support such activities, which align with student perceptions in our study. A recent study found that attendings’ lack of comfort with their knowledge was a barrier to discussing basic science on inpatient rounds.⁴⁷ Even if clinical educators feel confident in their basic science knowledge, they may lack formal understanding of how to support students in connecting basic science to patient care activities,¹³ instead emphasizing factual recall rather than application.⁴⁸ They also may not see that they have a responsibility to support integration, connection, or transfer.^27,35,48 More studies are needed to better understand the perspectives of clinical educators regarding their knowledge, perceived responsibility, behaviors, approaches, and self-efficacy around supporting their students’ connections to basic science knowledge, which would inform faculty development.

The literature commonly suggests the importance of collaboration between clinical and basic science educators but is unclear on how this might be operationalized in the workplace, and most faculty development efforts in this area have been directed toward classroom teachers. Clinical faculty training in cognitive apprenticeship could be helpful,³³ but may not directly address faculty discomfort associated with basic science knowledge. Consideration of a social constructivist⁴⁹ perspective on learning and faculty development may prove useful, in which knowledge is co-constructed by multiple people in the learning environment.^50,51 A model in which students and clinical supervisors share different types of knowledge (e.g. by students sharing biochemistry knowledge and supervisors sharing experiential and clinical knowledge) could promote learning for both parties, and lessen discomfort associated with the notion of clinical faculty being expected to know detailed biochemistry. Pai and colleagues’ proposed one concrete approach; in their “constructivist model” students present to the rounds team a brief basic science topic dictated by the patient condition, and clinician educators on the team facilitate further team discussion by asking open-ended questions.⁴⁷

Another critical influence on our participants’ connections to biochemistry was the medical conditions particular to each clerkship specialty. We propose that the “patients seen” within each clerkship represents an underexplored aspect of the physical domain of the learning environment⁵² that should be considered in addressing student basic science knowledge use and integration. Conditions and clerkships that offered connections to biochemistry knowledge in our study align with those catalogued in previous curriculum mapping efforts.²⁶ In addition, clerkship and specialty practice “patients seen” have been delineated by national clerkship education organizations based on expert input^53,54 and more recently are being captured and categorized using actual chart data.⁵⁵ Having an explicit map of such linkages between basic science concepts and authentic patient conditions within clerkships could enhance clinical supervisors’ efforts to support students’ connections at the bedside, and/or could enhance student-directed efforts. We note that the clerkships identified most often in our study as connection points for biochemistry knowledge do have associated activities (e.g. didactics or small group discussions) designed to deliberately revisit biochemistry. This suggests that the presence of such concurrent activities could enhance likelihood of connecting at the bedside, especially if planned based on a robust map of authentic linkages between basic science and patient care.

Tools that could be used to support connections and knowledge integration, especially if designed with understanding of conditions that afford connections, could prove powerful. Worked examples, defined as representations of problem solutions that illustrate how a proficient problem solver would proceed, reflect social cognitive learning principles,³² and could provide important modeling for faculty and students. Teaching scripts⁴³ have been described that provide worked examples of basic science knowledge integration for faculty, possibly enhancing their own self-efficacy for modeling or engaging with students in other ways. Students in our study highlighted the importance of tools and visuals provided to them in the preclerkship phase of the curriculum, suggesting utility in design of “transfer tools”⁵⁶ that when provided to students support making connections between their preclerkship learning and patient care activities, either independently or with clinical supervisors. Integrated Illness Scripts⁵⁷, which have been described as a text- and visual-based representations of basic science and clinical information organized into a framework that explicitly illustrates linkages between clinical features and causal mechanisms, represent another type of worked example that could support development of both faculty and students’ knowledge and self-efficacy.

The post-core clerkship timing of USMLE Step 1 in the curriculum may influence students’ ability to recognize useful connections to biochemistry, in this case further driving the perception of a basic science disconnect. Echoing prior studies,³³ participants described this exam as emphasizing the learning of biochemistry minutiae that was neither emphasized in the pre-clerkship curriculum, nor reinforced during the clerkship phase of learning, which was a source of frustration. While we did not identify thematically that students’ lack of biochemistry knowledge was necessarily a barrier to making connections during clerkships, they acknowledged that there was little expectation for them to do so. Rather, a perceived lack of knowledge posed a bigger hindrance in starting Step 1 study. The timing of this exam is known to influence student perceptions of basic science value⁴² and may be at play in students’ reporting on the AAMC Graduation Questionnaire that their study of biochemistry does not prepare them well for clerkships.¹⁸ The latter data have driven significant manipulation of the pre-clerkship curriculum, perhaps in a futile manner given that participants still reported this disconnect. Student frustration about the misalignment of the information tested on Step 1 and what is expected of them in clerkships may shift now that USMLE Step 1 is pass/fail. Regardless, we advocate more deliberate consideration of ways to harness the post-core clerkship Step 1 study period to better support knowledge integration. Kercheval and colleagues described how students’ reflections on connection of conceptual learning to authentic patient care experiences were powerful learning moments,³³ Given the importance of reflection in Peters and colleagues’ transfer model,³⁵ deliberately designed reflection activities in this phase of learning could optimize student learning.

Moving forward, we caution that manipulation of pre-clerkship curricula with the goal of supporting basic science knowledge integration and transfer may not achieve desired results. The setting for this study is an institution with a curriculum that emphasizes integration of basic and clinical sciences at the program- and clerkship-level.⁵⁸ The design of the pre-clerkship biochemistry curriculum follows approaches described in the literature to support transfer of basic science knowledge^14,20 including organization around concepts; emphasis on connection of those concepts to signs, symptoms, and treatment of common diseases; de-emphasis of memorization in favor of deep learning; and provision of opportunities to revisit biochemistry in classroom sessions connected to specific clerkships. Yet, participants articulated infrequent connections between their classroom and clerkship learning and even surprise that they were not expected to more deliberately use their biochemistry knowledge. Given the workplace is the setting in which we ultimately aim to see the fruits of pre-clerkship labors, we encourage continued examination of ways that elements of the clinical learning environment interact with students’ personal factors and behaviors to influence their learning.

There are some limitations to this study. We relied on student interview data only; future studies that address the perceptions of other stakeholders in the learning environment would enrich understanding. The pre-clerkship biochemistry assessment scores in our sample reflected those of the class; however, this sample may not fully represent the experience of students in other classes or institutions. Also, students who self-selected to participate might be better able to articulate their connections. Our focus on biochemistry may limit transferability of our findings to other basic science disciplines, though findings were similar to others in anatomy.¹⁴ Although the sample size was limited, the results showed focus and recurrence of concepts, and findings from prior work³⁸ suggested thematic and meaning sufficiency. Finally, we did not collect demographic information from participants. Although we did not have reason to believe that participants’ responses to our questions would be influenced significantly by race, sex, gender, or other identity variables this choice may have limited our interpretations.

Conclusion

The frequency, number, and character of explicit connections to biochemistry knowledge needed to practice effective patient care in the clinical workplace remains unclear. The value that students derive from these connections suggests such opportunities should not be missed. Responsibility for biochemistry knowledge use, integration, and transfer in the workplace should be shared between clinical faculty and students, though deeper exploration of how to empower each to support these processes is needed. Given the view, according to social cognitive theory, that transfer is influenced by an interplay of personal, behavioral, and environmental factors, we encourage medical educators and researchers to increase attention on the context of the clinical workplace when designing instructional interventions and faculty development to support connections, integration, and transfer.

Declaration of interest statement

The authors have no conflicts of interest to report.

Acknowledgements

The authors thank Esteban Dell’Angelica and Sebastian Uijtdehaage for discussions that inspired this work, and David Irby for a robust review of an early version of the manuscript. They also thank the student participants for their time and thoughtful responses; faculty and learners in the UMC Utrecht program for providing critical feedback; and the UCSF Center for Faculty Educators and the UCSF Academy of Medical Educators for funding through the Endowed Chair for Excellence in Foundational Teaching, held by TBF. The authors are especially grateful for the feedback from the journal’s reviewers and editors.

Additional information

Funding

TBF holds the UCSF Academy of Medical Educators Endowed Chair for Excellence in Foundational Teaching, which provided funding that supported this work.