A new theory of the development of expertise in medicine is outlined. Contrary to existing views, this theory assumes that expertise is not so much a matter of superior reasoning skills or in-depth knowledge of pathophysiological states as it is based on cognitive structures that describe the features of prototypical or even actual patients. These cognitive structures, referred to as "illness scripts," contain relatively little knowledge about pathophysiological causes of symptoms and complaints but a wealth of clinically relevant information about disease, its consequences, and the context under which illness develops. By contrast, intermediate-level students without clinical experience typically use pathophysiological, causal models of disease when solving problems. The authors review evidence supporting the theory and discuss its implications for the understanding of five phenomena extensively documented in the clinical-reasoning literature: (1) content specificity in diagnostic performance; (2) typical differences in data-gathering techniques between medical students and physicians; (3) difficulties involved in setting standards; (4) a decline in performance on certain measures of clinical reasoning with increasing expertise; and (5) a paradoxical association between errors and longer response times in visual diagnosis.

The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Theory raises questions about how illness scripts develop and are refined with clinical experience. It also provides a framework to assist their acquisition.

In two experiments, the effects of level of medical expertise and study time on free recall of a clinical case were assessed. In Experiment 1, a nonmonotonic relationship between level of expertise and recall was found: Subjects of intermediate levels of expertise remembered more information from the case than both experts and novices. This "intermediate effect" disappeared, however, when study time was restricted. Analysis of post hoc acquired protocols ofpathophysiological knowledge active during case processing suggested that this phenomenon could be attributed to the nature of the pathophysiological knowledge mobilized to comprehend the case. In Experiment 2, this assumption was directly tested by priming relevant pathophysiological knowledge for either a short or a longer period, before enabling subjects to study the case briefly. Free-recall data confirmed and extended the results of Experiment 1. Again, an intermediate effect was found; this time, however, it was generated experimentally. The findings were interpreted in terms of qualitative differences in the nature of the knowledge structures underlying performance between novices, advanced students, and medical experts: Experts use knowledge in an encapsulated mode while comprehending a case, whereas students use elaborated knowledge.The intermediate effect in clinical case representation studies is among the best-known, stable, and hitherto unexplained phenomena in medical expertise research. The quasi-experimental paradigm that produces this phenomenon is described as follows: Subjects differing in level of expertise are requested to study, for about 2 or 3 min, half a page oftext describing a patient's history, presenting complaint and some additional findings such as results of laboratory tests and physical examination. The text is removed, and the subjects are asked to recall everything they can remember from the text. Subjects of intermediate levels of expertise consistently produce more elaborate recalls than either experts (e.g., experienced physicians) or novices. This phenomenon has been demonstrated under various conditions, with different cases and in different populations (Claessen & Boshuizen, 1985;Hassebrock, Bullemer, & Johnson, 1988;Muzzin, Norman, Feightner, & Tugwell, 1983; Patel & Groen, 1986b). The intermediate effect has also been demonstrated in expertise-related tasks other than text processing (Grant & Marsden, 1988;Patel, Evans, & Kaufman, 1988).These findings appear to be counterintuitive. Spilich, Vesonder, Chiesi, and Voss (1979) shown that subjects with a high knowledge of baseball remembered more, and more relevant, information from a report of a baseball game than low-knowledge individuals. Theories of text processing, generally, assume that prior knowledge facilitates new information to be encoded and retrieved. The more prior knowledge a person has, the more he/she will be able to recall from the stimulus material (Graesser & Clark, 1985;Voss & Bisanz, 1985). In other words, instead of the inverted U-shaped curve comm...

This article presents a new theory of expertise development in medicine and

The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.

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Clerkship education has been called a 'black box' because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers pub-lished over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors' and many other health workers' interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors' teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase 'supported participation in practice' best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within rela-tionships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow's doctors.Shareable link http://rdcu.be/Fxjh