From theory to therapy: the development of therapy scripts in medical students

Therapeutic reasoning is a complex process prone to errors, particularly among junior doctors under time pressure. While experienced clinicians often rely on Type 1 (intuitive) thinking via therapy scripts, little is known about how these scripts develop during medical training. Insight into how therapy scripts develop and evolve could inform Clinical Pharmacology and Therapeutics (CPT) education and improve the safety of early-career prescribing.

We carried out a qualitative think-aloud study with 15 medical students from years 2, 4, and 6. Students completed a diabetes case while verbalizing their reasoning, and then created a concept map and reflective questions. Transcripts were analysed using abductive thematic analysis, guided by Cook's therapy script framework and knowledge encapsulation theory. Concept maps were evaluated for structural complexity and richness of reasoning. Results were compared across the three groups of students, to investigate differences in therapy script development.

Therapy script development progressed from fragmented, mechanism-focused reasoning in second-year students to integrated, patient-centred reasoning in sixth-year students. Fourth-year students combined both forms of reasoning. Concept maps revealed that structural complexity and higher-level explanatory connections increased with training.

Therapy scripts develop gradually, with increasing integration and contextual sensitivity, during undergraduate medical training. Concept mapping supports reflection and reveals gaps in knowledge, complementing traditional teaching methods. Educational strategies that promote early, structured, and reflective reasoning may accelerate therapy script formation, improve metacognitive awareness, and reduce the gap between undergraduate training and safe, effective prescribing in clinical practice.